Nurse Specialist II

Qlarant

11h•Hybrid

About The Position

The Nurse Specialist II performs medical record and claims review for Medicare, Medicaid, and/or other claims data to ensure proper guidelines are followed and to assess for potential overpayment, fraud, waste, and abuse. This role involves reviewing beneficiary, provider, and/or pharmacy cases, completing desk reviews or field audits, consulting with investigation experts, and preparing case summaries for investigators. The specialist may also participate in focus groups, provider onsite visits, beneficiary interviews, and legal proceedings as needed. Additionally, the role includes providing job-specific orientation and training, and helping to develop training content and resources.

Requirements

Minimum Bachelor's Degree required
2 - 4 years of experience required
Current, active and non-restricted RN licensure required

Nice To Haves

5 - 7 years experience preferred
Medical Review experience preferred; specifically in Medicare or Medicaid
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.