Nurse Specialist II at Qlarant

United States

$56.055k - $85k

Job Summary: Performs medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed and assesses for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and/or other claims.  Essential Functions: * Reviews beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse. * Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud. * Consults with benefit integrity investigation experts and pharmacists for advice and clarification. * Completes case summaries and provides results to investigators to support the investigative process. * Provides case specific or plan specific data entry and reporting. * Participates in internal and external focus groups, as required. * Participates in provider onsite visits and beneficiary interviews, as required, for field audits/investigations. * Testifies at various legal proceedings, as necessary. * Provides job-specific orientation and training, as needed. Helps develop training content, resources, and programs specific to job functions. Level of Supervision Received: Plans and arranges own work; works with manager to prioritize projects Education (can be substituted for experience): Minimum Bachelor's Degree preferred, RN license required Work Experience (can be substituted for education): 2 - 4 years of experience in medical claims review required; 5 - 7 years preferred  Certification(s): Current, active and non-restricted RN licensure required Coding certification preferred