Nurse Specialist II

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

📋 Description

• Conduct reviews of medical records and claims for Medicare, Medicaid, and/or other claims data.

• Ensure adherence to relevant guidelines while evaluating potential overpayments, fraud, waste, and abuse.

• Analyze cases related to beneficiaries, providers, and/or pharmacies.

• Execute desk reviews or field audits to fulfill contract obligations and uncover evidence of possible overpayment or fraud.

• Collaborate with benefit integrity investigation specialists and pharmacists.

• Generate case summaries and deliver findings to investigators.

• Perform data entry and reporting specific to cases or plans.

• Engage in internal and external focus groups as needed.

• Participate in onsite provider visits and beneficiary interviews for field audits/investigations as required.

• Provide testimony during legal proceedings when necessary.

• Offer job-specific orientation and training.

• Assist in the creation of training materials, resources, and programs.

• Organize and plan your work with collaboration from the manager regarding project priorities.

⛳️ Requirements

• A minimum of a Bachelor's Degree is required; education may be substituted for relevant experience.

• 2 to 4 years of professional experience is required; 5 to 7 years is preferred.

• Experience in medical claims review is required.

• Familiarity and experience with Medicare/Medicaid is preferred.

• A current, active, and unrestricted RN license is required.

• Coding certification is preferred.

• Capability to conduct medical record and claims reviews.

• Proficiency in completing desk reviews and field audits.

• Ability to perform data entry and reporting tasks.

• Competence to provide testimony during legal proceedings when necessary.

• Successful completion of pre-employment background checks and drug screenings is required.

🏝️ Benefits

• Equal Opportunity Employer for Minorities, Females, Protected Veterans, and Individuals with Disabilities.

• A drug-free workplace.

• Employment offers are contingent upon the successful completion of pre-employment background checks and drug screenings.