Nurse Reviewer

Orchard•Remote U.S., TX

6d•Remote

About The Position

@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 for large organizations across the country. In addition, our client operates a foundation providing grant opportunities to those with programs for under-served communities. Our client is seeking an experienced Nurse Reviewer to perform 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. Must reside within the contract jurisdiction: TX, AR, CO, LA, MS, NM, OK

Requirements

Minimum Bachelor's Degree preferred, RN license required
2 - 4 years of experience in medical claims review required; 5 - 7 years preferred
Current, active and non-restricted RN licensure required.

Nice To Haves

ICD-9 coding and CPT coding knowledge strongly preferred.
Coding certification preferred

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