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Medical Review RN – Medicare A&B/Medicaid

Remote

Full-Time/Regular

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 iniduals 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 under-served communities.

Qlarant has an exciting opportunity for an experienced Medical Review RN (Claims Analyst II) to join our Unified Program Integrity Contractors (UPIC) West team. Our UPIC team identifies and investigates fraud, waste and abuse in the Medicare Parts A & B and Medicaid programs covering 16 Western states and territories. The selected candidate can be home based in most states in the U.S.

Please Note: Current, active and non-restricted RN license required. An LVN will not meet requirements.

This mid-level professional performs medical record and claims review for Medicare Parts A&B, 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 include some or all of the following. Other duties may be assigned.

• 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 for advice and clarification.
• Completes inquiry letters, investigation finding letters, and case summaries.
• Investigates and 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 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.
• Understands and complies with the company’s policies and procedures pertaining to compliance with HIPAA.
• 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.

Required Skills

To perform the job successfully, an inidual should demonstrate the following competencies:

• Analytical – Synthesizes complex or erse information; Collects and researches data; Uses intuition and experience to complement data.
• Problem Solving – Gathers and analyses information skillfully; Identifies and resolves problems.
• Judgment – Supports and explains reasoning for decisions.
• Written Communication – Writes clearly and informatively; Able to read and interpret written information.
• Quality Management – Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
• Interpersonal Skills – Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others’ ideas and tries new things.
• Teamwork – Balances team and inidual responsibilities; Exhibits objectivity and openness to others’ views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; able to build morale and group commitments to goals and objectives; Supports everyone’s efforts to succeed.
• Professionalism – Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
• Other Skills and Abilities
  • To perform this job successfully, an inidual should have intermediate level knowledge of Microsoft Office and the internet to meet contract deliverables.
  • Utilizes required data entry and reporting systems, including advanced features.
  • Must have the ability to work independently with minimal supervision.
  • Must be able to communicate effectively with all members of the team to which he/she is assigned.

Required Experience

Education and/or Experience

• BSN OR an 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 years clinical experience.
• At least one year healthcare experience that demonstrates expertise in conducting medical records and claims reviews and/or 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.

Certificates, Licenses, Registrations: Current, active and non-restricted RN licensure required. An LVN will not be accepted.

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Iniduals with Disabilities.