Nurse Specialist II
克拉兰特是一家非营利性公司，与公共和私营部门合作，创建高质量，安全和有效的医疗保健和人力服务计划。我们拥有多个行业，包括人口健康，利用情况审查，管理护理组织质量评估以及为发展残疾人士提供服务的项目质量保证。克拉朗特也是全国各地大型机构打击欺诈，浪费和滥用的国家领导者。此外，我们的基金会为那些对未受惠社区的项目提供赠款机会。最佳人员，最佳解决方案，最佳结果工作总结：执行医疗记录和索赔审查，以确保遵守适当的指南并评估潜在过度支付，欺诈，浪费和滥用与 Medicare, Medicaid 和/或其他索赔有关的医疗记录，医疗补助和/或其它索赔数据。基本功能：· 对受益者，提供商和/或药店案件进行审查，以查看可能过度支出的情况，欺诈性，废弃性和滥用的情况。·完成办公桌检查或现场审计来满足适用于合约要求以及确定潜在过度偿还或欺诈性的证据。·咨询利益完整性调查专家和药师获取建议和澄清。· 完成案例总结，并为调查人员提供结果以支持调查过程。· 提供具体案件或计划特定数据输入和报告。· 根据需要参与内部和外部焦点组。· 按照要求参加供应商现场访问和受益者采访。· 在必要时进行实地审计/调查。· 证明在各种法律程序中，如有必要。· 按需提供工作指导和培训。帮助制定专业职能的培训内容，资源和方案。受理监督水平：规划和安排自己的工作；与经理合作优先考虑项目。工作经验：需要2~4年经验；需5~7年的优先医疗审查经验；必须与医保或医疗补助机构合作的经验；要求目前，活跃和无限制的 RN 许可证。
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Qlarant is 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. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for underserved communities.
Best People, Best Solutions, Best Results
Job Summary:
Performs 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.
Essential Functions:
- 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.
Level of Supervision Received:
Plans and arranges own work; works with manager to prioritize projects
Education (can be substituted for experience):
Minimum Bachelor's Degree required
Work Experience (can be substituted for education):
2 - 4 years of experience required; 5 - 7 years preferred
Medical Review experience required
Experience working with Medicare or Medicaid preferred
Certification(s):
Current, active and non-restricted RN licensure required
Coding certification preferred
Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.
Qlarant is a drug-free workplace. All offers of employment are contingent upon successful completion of pre-employment background and drug screens.
Originally posted on Himalayas