Claims Analyst II - Medical Review RN - Medicare Part C - 27744410-5296
About the position
The Claims Analyst II - Medical Review RN position at Orchard LLC involves evaluating medical claims data to detect and prevent fraud, waste, and abuse in the Medicare Part C program. This mid-level role requires strong analytical skills and the ability to perform medical record and claims reviews, ensuring compliance with guidelines. The position is home-based and full-time, offering excellent benefits.
Responsibilities
Ā 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.
,
Ā Complete desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
,
Ā Effectively identify and resolve claims issues and determine root cause.
,
Ā Interact with beneficiaries and health plans to obtain additional case specific information, as needed.
,
Ā Consult with Benefit Integrity investigation experts for advice and clarification.
,
Ā Complete inquiry letters, investigation finding letters, and case summaries.
,
Ā Investigate and refer all potential fraud leads to the Investigators/Auditors.
,
Ā Perform case specific or plan specific data entry and reporting.
,
Ā Participate in internal and external focus groups and other projects, as required.
,
Ā Identify opportunities to improve processes and procedures.
,
Ā Testify at various legal proceedings as necessary.
,
Ā Mentor and provide guidance to junior and level one analysts.
Requirements
Ā BSN OR an RN with additional current and active degree/license/certification in a relevant healthcare discipline (i.e., CPC, CPHM, CFE, CCM, HCAFA), or willingness to obtain CPC.
,
Ā Current, active, and non-restricted RN licensure required.
,
Ā At least five years clinical experience.
,
Ā At least one year of healthcare experience that demonstrates expertise in utilization reviews.
,
Ā Strong understanding of Excel.
Nice-to-haves
Ā Medicaid/MCO review experience strongly preferred.
,
Ā ICD-9 coding, CPT coding, and knowledge of Medicaid regulations strongly preferred.
,
Ā Experience with Medicaid Utilization Management with understanding of how to apply hierarchies preferred.
,
Ā Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.
Benefits
Ā Work from home within the Continental United States
,
Ā Excellent benefits package
Apply Now
The Claims Analyst II - Medical Review RN position at Orchard LLC involves evaluating medical claims data to detect and prevent fraud, waste, and abuse in the Medicare Part C program. This mid-level role requires strong analytical skills and the ability to perform medical record and claims reviews, ensuring compliance with guidelines. The position is home-based and full-time, offering excellent benefits.
Responsibilities
Ā 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.
,
Ā Complete desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
,
Ā Effectively identify and resolve claims issues and determine root cause.
,
Ā Interact with beneficiaries and health plans to obtain additional case specific information, as needed.
,
Ā Consult with Benefit Integrity investigation experts for advice and clarification.
,
Ā Complete inquiry letters, investigation finding letters, and case summaries.
,
Ā Investigate and refer all potential fraud leads to the Investigators/Auditors.
,
Ā Perform case specific or plan specific data entry and reporting.
,
Ā Participate in internal and external focus groups and other projects, as required.
,
Ā Identify opportunities to improve processes and procedures.
,
Ā Testify at various legal proceedings as necessary.
,
Ā Mentor and provide guidance to junior and level one analysts.
Requirements
Ā BSN OR an RN with additional current and active degree/license/certification in a relevant healthcare discipline (i.e., CPC, CPHM, CFE, CCM, HCAFA), or willingness to obtain CPC.
,
Ā Current, active, and non-restricted RN licensure required.
,
Ā At least five years clinical experience.
,
Ā At least one year of healthcare experience that demonstrates expertise in utilization reviews.
,
Ā Strong understanding of Excel.
Nice-to-haves
Ā Medicaid/MCO review experience strongly preferred.
,
Ā ICD-9 coding, CPT coding, and knowledge of Medicaid regulations strongly preferred.
,
Ā Experience with Medicaid Utilization Management with understanding of how to apply hierarchies preferred.
,
Ā Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.
Benefits
Ā Work from home within the Continental United States
,
Ā Excellent benefits package
Apply Now