Bilingual Nurse Reviewer – Medicaid

This is a fully remote position, open to applicants in United States.

📋 Description

• Perform reviews of medical records and utilize sound clinical judgment to make decisions regarding claim payments.

• Investigate medical claims data and other pertinent information to pinpoint issues.

• Analyze complex data model outputs and employ tools to uncover potential fraudulent activities.

• Assist in ongoing fraud investigations and fulfill information requests.

• Identify and create cases for future administrative measures, such as law enforcement referrals, educational initiatives, and recovery of overpayments.

• Collaborate with external agencies to formulate cases and corrective actions.

• Address requests for data and provide necessary support.

• Highlight issues of concern, referencing regulatory violations and alleging schemes or scams aimed at defrauding the Government.

• Investigate regulations and document violations.

• Conduct independent research on Medicaid payments to both institutional and non-institutional providers.

• Testify in court regarding findings from work when necessary.

• Draft correspondence, reports, and summary letters for referrals.

• Maintain effective communication both internally and externally.

• Manage confidential information with discretion.

• Report work activities promptly.

• Work autonomously as well as collaboratively within a team environment.

• Participate in meetings, training sessions, and conferences as required.

⛳️ Requirements

• Bachelor’s degree with 5 years of experience, Master’s degree with 3 years of experience, or Associate’s degree with 7 years of experience.

• A minimum of 3 years of experience in the medical field as a Registered Nurse or another clinician, and/or experience in reviewing medical claims for coverage and medical necessity.

• Current/Active Nursing or Physical Therapy license in the state of residence.

• Exceptional investigative skills.

• Strong communication and organizational abilities.

• Proficient PC knowledge and skills.

• U.S. citizenship is mandatory.

• Bilingual proficiency in speaking and writing in both English and Spanish.

• Experience in reviewing claims for technical requirements, conducting medical reviews, and/or developing fraud cases.

• Familiarity with Medicaid requirements, laws, rules, and regulations related to service billing.

• CPC (Certified Professional Coder) certification is preferred.

🏝️ Benefits

• Telework options available for employees residing in the contiguous United States.

• Overnight travel may be necessary.

• Employees might be eligible for overtime, shift differentials, and discretionary bonuses in addition to base salary.