Nurse Specialist II
Location
United States
Posted
3 days ago
Salary
$64.5K - $95K / year
Job Description
Role Description
Performs medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed and assesses for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and/or other claims.
- Reviews beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse.
- Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
- Consults with benefit integrity investigation experts and pharmacists for advice and clarification.
- Completes case summaries and provides results to investigators to support the investigative process.
- Provides case specific or plan specific data entry and reporting.
- Participates in internal and external focus groups, as required.
- Participates in provider onsite visits and beneficiary interviews, as required, for field audits/investigations.
- Testifies at various legal proceedings, as necessary.
- Provides job-specific orientation and training, as needed. Helps develop training content, resources, and programs specific to job functions.
Qualifications
- Minimum Bachelor's Degree required.
Requirements
- 2 - 4 years of experience required; 5 - 7 years preferred.
- Current, active and non-restricted RN licensure required.
- Coding certification preferred.
Job Requirements
- Minimum Bachelor's Degree required.
- 2 - 4 years of experience required; 5 - 7 years preferred.
- Current, active and non-restricted RN licensure required.
- Coding certification preferred.
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