Medical Review RN - MIC
Quality Health Strategies - Easton, MD

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Essential Duties and Responsibilities include, but are not limited to, some or all of the following: ·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 audits to ensure completeness and to identify evidence of potential overpayment or fraud. ·Effectively identifies and resolves claims issues and determines root cause. ·Interacts with beneficiaries, health plans, and medical service providers 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. ·Has basic understanding of the use of the desktop computer for entry and research. ·Responsible for case specific or plan specific data entry and reporting. ·Participates in internal and external focus groups, 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. ·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.

Required Skills A BSN or an RN with additional degree/licensure/certification in a relevant healthcare discipline (i.e., CPC, CCM, CFE). Must possess at least five years acute care clinical experience. One to two years 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.

Required Experience 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.

Quality Health Strategies - 16 months ago - save job - block