Nurse Specialist II

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 preferred, RN license required

Work Experience (can be substituted for education): 2 - 4 years of experience in medical claims review required; 5 - 7 years preferred

Certification(s): Current, active and non-restricted RN licensure required Coding certification preferred