Medical Review Rn -Experienced - Home Or Office Based

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.

Are you a Registered Nurse with strong clinical experience as well as a background in medicare/medicaid claims review and related areas? Do you have a working knowledge of Medicare and/or Medicaid and a desire to make a difference in the future of our nation's healthcare programs? If the answer is yes, then we have the perfect opportunity for you!

Qlarant has exciting opportunities for experienced Medical Review RNs (Claims Analyst II) to join our Dallas, TX based Unified Program Integrity Contractors (UPIC) team. Our UPIC SW team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 7 Southwestern states. We're seeking candidates with a track record of meeting deliverables and exceeding expectations.

The selected candidates can be based in our Dallas office or well qualified candidates residing within the UPIC SW jurisdiction (Texas, Louisiana, Mississippi, Arkansas, Oklahoma, Colorado and New Mexico) may be considered for home-based opportunities.

Please Note: This is not an entry-level position and a current, active and non-restricted RN license required. An LVN will not meet CMS requirements.

This is a Mid-level professional position performing 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.

• Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
• May mentor and provide guidance to junior and level one analysts.
• Identifies opportunities to improve processes and procedures.
• 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.
• Investigates and refers all potential fraud leads to the Investigators/Auditors.
• Interacts with beneficiaries and health plans to obtain additional case specific information, as needed.
• Performs a variety of tasks some requiring independent thought and research. A degree of creativity and latitude is required.
• Testifies at various legal proceedings as necessary.
• Has basic understanding of the use of the computer for entry and research.
• Completes inquiry letters, investigation finding letters, and case summaries.
• Participates in internal and external focus groups and other projects, as required.
• Has developed expertise with standard concepts, practice and procedures in field. Relies on limited experience and judgment to plan and accomplish goals.
• 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
• Responsible for case specific or plan specific data entry and reporting.
• Effectively identifies and resolves claims issues and determines root cause.
• Consults with Benefit Integrity investigation experts and pharmacists for advice and clarification.

Required Skills

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.
• Written Communication - Writes clearly and informatively; Able to read and interpret written information.
• 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.
• 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.
• Judgment - Supports and explains reasoning for decisions.
• Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
• Problem Solving – Gathers and analyses information skillfully; Identifies and resolves problems.
• 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.

Required Experience

Education and/or Experience

• At least one year healthcare experience that demonstrates expertise in conducting medical reviews.
• 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).
• ICD-9 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations preferred. CPC or similar certification preferred.
• Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.
• Must possess at least five years clinical experience or combination of clinical and medical review experience.

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.