Medical Review Nurse

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 under-served communities.

Best People, Best Solutions, Best Results

Job Summary:

Mid-level professional performs medical record and claims review for Medicare, 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.

• 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.
• 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 and pharmacists 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.
• 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.

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

• Analytical - Synthesizes complex or diverse 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 individual 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.

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 utilization reviews.
• ICD-9 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations 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.

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