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