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 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 Medical Review RN Lead to join their Investigation clinical team. Senior level professional performs high-level medical record and claims review for Medicare, Medicaid, or other claims data in order to ensure that proper guidelines have been followed and acts as a facilitator as well as a case manager regarding potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and other medical claims.
Essential Duties and Responsibilities
Review Explanation of Benefit (EOB) cases, beneficiary, provider, and 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.
Effectively identifies claims issues and determines root cause.
Interacts with beneficiaries, health plans, and medical service providers to obtain additional case specific information, as needed.
Consults with Benefit Integrity experts for advice and clarification.
Completes inquiry letters, investigation finding letters, and case summaries.
Refers all potential fraud leads to the Investigators/Auditors.
Has basic understanding of the use of the computer for entry and research.
Responsible for case specific or plan specific data entry and reports.
Participates in internal and external focus groups and other projects, as required.
Identifies opportunities to improve processes and procedures.
Has the responsibility and authority to perform their job and provide customer satisfaction.
May participate as an audit/investigation team member for both desk and field audits/investigations.
Testifies at various legal proceedings as necessary.
Highly proficient in applying a large variety of more complex concepts, practices and procedures within the field.
Relies on extensive experience and judgment to plan and accomplish goals.
Performs a variety of the more complex tasks requiring a wide degree of creativity and latitude.
May lead or direct the work of others, providing training and quality assurance for their work.
Provides job specific orientation and training when called upon. With the Technical Trainer, the manager or others to develop training content, resources and programs specific to job functions.
Documents records of training that include scheduling, registration and attendance, quality control of training products and evaluation summaries.
Supervisory Responsibilities:
May directly supervise employees.
Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws.
Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
Your background will include.
A BSN or RN with additional current and active degree/license/certification/s in a relevant healthcare discipline (i.e., CPC, CPHM, CCM, CFE, HCAFA).
Current, active and non-restricted RN licensure required.
Minimum five years clinical experience.
Healthcare experience that demonstrates expertise in conducting utilization reviews, ICD-9 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations preferred.
Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.
Travel Requirements
Depending on contract requirements, regular travel required, including overnight travel of up to 5 days per month which may require use of personal/rental vehicle for travel within the region.
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.
