Claims Analyst - Medical Review RN

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 (Claims Analyst II) to join their Investigation clinical team. The role requires superior analytical skills and a proven ability to evaluate medical claims data. If you love digging into the data, this is the perfect job for you! As a Claims Analyst II, you will play a key role on the team that detects and prevents fraud, waste, and abuse in the Medicare Part C program on a national level. This is a home-based, full-time position with excellent benefits.

About the Claims Analyst II (RN) role.

Mid-level professional performs medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed. As a member of an investigative team, may act as a facilitator as well as a case manager regarding assessment for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and/or other claims.

Essential Duties and 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.

• Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
• Effectively identifies and resolves claims issues and determines root cause.
• Interacts with beneficiaries and health plans to obtain additional case specific information, as needed.
• Consults with Benefit Integrity investigation experts and pharmacists for advice and clarification.
• Completes inquiry letters, investigation finding letters, and case summaries.
• Investigates and refers all potential fraud leads to the Investigators/Auditors.
• Use understanding of the computer for data entry and research.
• Responsible for case specific or plan specific data entry and reporting.
• 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
• Has developed expertise with standard concepts, practice and procedures in field. Relies on limited experience and judgment to plan and accomplish goals.
• Testifies at various legal proceedings as necessary.
• May mentor and provide guidance to junior and level one analysts.
• Performs a variety of tasks some requiring independent thought and research. A degree of creativity and latitude is required.

• BSN or RN with additional current and active degree/license/certification/s in a relevant healthcare discipline (i.e., CPC, CPHM, CFE, CCM, HCAFA).
• Must possess at least five (5) years clinical experience.
• At least one year healthcare experience that demonstrates expertise in conducting utilization reviews.
• ICD-9 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations strongly preferred.
• Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.

• Current, active and non-restricted RN licensure required.