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 established guidelines and evaluate potential instances of overpayment, fraud, waste, and abuse.

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

• Execute desk reviews or field audits to comply with contract obligations and detect signs of potential overpayment or fraud.

• Collaborate with experts in benefit integrity investigations and pharmacists.

• Prepare case summaries and relay findings to investigators.

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

• Engage in internal and external focus groups as needed.

• Take part in provider onsite visits and beneficiary interviews for field audits/investigations.

• Provide testimony at legal proceedings when required.

• Deliver job-specific orientation and training.

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

• Organize and manage personal workload while collaborating with the manager to prioritize projects.

⛳️ Requirements

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

• 2 - 4 years of relevant experience is necessary; 5 - 7 years is preferred.

• Medical Review experience is mandatory.

• Experience with Medicare or Medicaid is preferred.

• Current, active, and non-restricted RN licensure is required.

• Coding certification is preferred.

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

• Must be able to participate in provider onsite visits and beneficiary interviews for field audits/investigations as needed.

• Must be capable of providing testimony at various legal proceedings when necessary.

🏝️ Benefits

• Comprehensive health insurance options.

• Retirement savings plan with employer contributions.

• Professional development opportunities available.

• Flexible work schedule options.

• Generous paid time off policy.