Medical Review RN / Nurse Specialist II

Work from Home within the Continental United States

@Orchard LLC is supporting a not-for-profit corporation that partners with public and private sectors to create high-quality, safe, and efficient delivery of health care and human services programs. Our client has multiple lines of business, including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Our client is also a national leader in fighting fraud, waste, and abuse by large organizations across the country. In addition, our client operates a foundation providing grant opportunities to those with programs for underserved communities.

About the role.

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.

Essential Duties and Responsibilities:

• 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. Help develop training content, resources, and programs specific to job functions.

Your background will include.

• Bachelor’s degree in Nursing or related (education can be substituted for experience).
• Must possess at least 2-4 years of medical review experience.
• At least one year of healthcare experience that demonstrates expertise in conducting utilization reviews/management.
• ICD-9 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations strongly preferred.
• Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.

Certificates, Licenses, Registrations

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

If you match the requirements for this opportunity and believe you have the experience and talent to succeed in the role, we need to hear from you!

Established in 2010, @Orchard LLC, also known as, Talent Orchard has an exceptional reputation, providing staffing solutions to time-sensitive, talent scarcity issues to deliver better talent management ROI. Our specialty lies in the critical area of program talent acquisition and resource management, not in one narrow skillset, but across many areas of technical and functional delivery. To learn more about our other exciting opportunities, visit our Jobs Page at www.atOrchard.com