Claims Analyst II - Medical Review RN - Medicare Part C - 27744410-5296

Orchard • Chicago, IL

420d • Remote

About The Position

The Claims Analyst II - Medical Review RN position at Orchard LLC involves evaluating medical claims data to detect and prevent fraud, waste, and abuse in the Medicare Part C program. This mid-level role requires strong analytical skills and the ability to perform medical record and claims reviews, ensuring compliance with guidelines. The position is home-based and full-time, offering excellent benefits.

Requirements

• BSN OR an RN with additional current and active degree/license/certification in a relevant healthcare discipline (i.e., CPC, CPHM, CFE, CCM, HCAFA), or willingness to obtain CPC.
• Current, active, and non-restricted RN licensure required.
• At least five years clinical experience.
• At least one year of healthcare experience that demonstrates expertise in utilization reviews.
• Strong understanding of Excel.

Nice To Haves

• Medicaid/MCO review experience strongly preferred.
• ICD-9 coding, CPT coding, and knowledge of Medicaid regulations strongly preferred.
• Experience with Medicaid Utilization Management with understanding of how to apply hierarchies preferred.
• Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.

Responsibilities

• Review Explanation of Benefit (EOB) cases, beneficiary, provider, and/or pharmacy cases for drug seeking, drug selling, beneficiary and other potential overpayment, fraud, waste, and abuse.
• Complete desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
• Effectively identify and resolve claims issues and determine root cause.
• Interact with beneficiaries and health plans to obtain additional case specific information, as needed.
• Consult with Benefit Integrity investigation experts for advice and clarification.
• Complete inquiry letters, investigation finding letters, and case summaries.
• Investigate and refer all potential fraud leads to the Investigators/Auditors.
• Perform case specific or plan specific data entry and reporting.
• Participate in internal and external focus groups and other projects, as required.
• Identify opportunities to improve processes and procedures.
• Testify at various legal proceedings as necessary.
• Mentor and provide guidance to junior and level one analysts.

Benefits

• Work from home within the Continental United States
• Excellent benefits package

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Crop Production
• Education Level: No Education Listed