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.

• Verify adherence to relevant guidelines.

• Evaluate potential overpayments, fraud, waste, and abuse.

• Analyze cases involving beneficiaries, providers, and/or pharmacies.

• Carry out desk reviews and field audits.

• Collaborate with benefit integrity investigation specialists and pharmacists.

• Prepare case summaries and deliver findings to investigators.

• Execute case-specific or plan-specific data entry and reporting tasks.

• Engage in internal and external focus groups as needed.

• Participate in onsite visits to providers and conduct beneficiary interviews for field audits/investigations.

• Provide testimony at legal proceedings when required.

• Deliver job-specific orientation and training.

• Assist in the development of training content, resources, and programs.

⛳️ Requirements

• A minimum of a Bachelor's Degree is required.

• Must possess a current, active, and unrestricted RN licensure.

• 2 to 4 years of relevant experience is required.

• Experience in Medical Review is essential.

• Preference will be given to candidates with Medicare experience.

• Coding certification is preferred.

• Must be willing to undergo pre-employment background and drug screenings.

🏝️ Benefits

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

• Commitment to a drug-free workplace.

• Pre-employment background and drug screenings are conducted.