Claims Analyst II - Medical Review RN - Medicare Part C

Orchard • Chicago, IL

422d • Remote

About The Position

The Claims Analyst II (Medical Review RN) role at Orchard LLC involves performing medical record and claims reviews for Medicaid/MCO and other claims data to ensure compliance with guidelines. This mid-level position is crucial in detecting and preventing fraud, waste, and abuse in the Medicare Part C program. The role requires strong analytical skills and the ability to evaluate medical claims data effectively, contributing to the overall integrity of healthcare delivery.

Requirements

• BSN or an RN with additional current and active degree/license/certification in a relevant healthcare discipline (e.g., CPC, CPHM, CFE, CCM, HCAFA), or willingness to obtain CPC.
• Current, active, and non-restricted RN licensure required.
• At least five years of clinical experience.
• At least one year of healthcare experience demonstrating expertise in utilization reviews.
• Strong understanding of ICD-9 coding, CPT coding, and Medicaid regulations preferred.
• Experience with Medicaid Utilization Management and understanding of hierarchies preferred.
• Prior experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.
• Strong understanding of Excel.

Nice To Haves

• Medicaid/MCO review experience strongly preferred.

Responsibilities

• Review Explanation of Benefit (EOB) cases, beneficiary, provider, and pharmacy cases for potential overpayment, fraud, waste, and abuse.
• Complete desk reviews or field audits to meet contract requirements and identify evidence of potential fraud or overpayment.
• Identify and resolve claims issues, determining root causes effectively.
• Interact with beneficiaries and health plans to gather 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 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 opportunity within the continental United States.
• Full-time position with excellent benefits.

What This Job Offers

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