Pre-Payment Review Nurse Consultant

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

📋 Description

• Performing clinical and financial pre-payment compliance assessments to identify, address, and eliminate fraud, waste, and abuse within the Medicaid program.

• Advising on the creation and execution of pre-payment review policies and guidelines that align with OIG program objectives.

• Conducting thorough medical record evaluations and analyzing intricate datasets and systems.

• Creating, establishing, and executing pre-payment review criteria across various service areas.

• Carrying out pre-payment reviews in accordance with medical necessity criteria, administrative codes, and additional requirements.

⛳️ Requirements

• Valid Wisconsin Registered Nurse license issued by the Wisconsin Department of Safety and Professional Services.

• Familiarity with contemporary medical concepts, practices, and techniques.

• Capability to evaluate statistical data and reports related to health service utilization trends.

• Understanding of laws, statutes, regulations, and rules pertaining to the state Medicaid program.

• Awareness of federal and state legislation relevant to Title XIX, Title XVIII, Title XX, and Title III.

• Ability to integrate medical knowledge and experience into the formulation of medical policy, administrative rules, and medical standards.

• Proficiency in developing standards and guidelines for monitoring medical practice patterns.

• In-depth understanding of Medicaid-covered services and reimbursement policies for analysis, recommendation formulation, and implementation.

• Skill in utilizing medical and financial records, claims, and claims data to gather documentation that supports audit or investigative conclusions.

• Familiarity with Generally Accepted Auditing Standards (GAAS).

• Proficiency in using computer-accessible databases to facilitate audit activities and technology employed in pre-payment review audits, including the examination and analysis of computer-generated reports.

• Extensive knowledge of hardware, software, and networking technologies relevant to changes in the healthcare industry.

• Understanding of program, financial, and accounting systems utilized by healthcare entities, including patient account management, billing processes, and reimbursement protocols.

• Comprehension of governmental and industry accounting and auditing standards or audit guides used for auditing healthcare providers.

• Ability to organize, prepare, summarize, and present information collected during audits or investigations in a clear and actionable manner to support valid findings and conclusions.

• Extensive expertise in technical writing, publication organization, preparation, and formatting.

• Proficiency in articulating the State’s stance on Medicaid issues—both verbally and in writing—in audit reports, investigative reports, exit conferences, and departmental meetings.

• Knowledge of records maintained by healthcare providers and the capacity to review medical records, patient charts, financial statements, transaction documentation, invoices, payroll records, and claims.

🏝️ Benefits

• Generous, flexible vacation policy

• 401(k) employer match

• Comprehensive health benefits

• Educational assistance

• Leadership and technical development academies