Medical Review RN - Medicare
HP - Chico, CA

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Medical Review RN - Medicare - 1127772

Description SafeGuard Services (SGS), a subsidiary of Hewlett-Packard Enterprise Services, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

Since 1999, SGS has prevented approximately $4 billion in inappropriate payments utilizing proactive claims processing system edits. SGS has additionally identified over $1 billion in overpayments recovered on a post-pay basis. Our experience with fraud and abuse analytics has resulted in the referral of hundreds of cases to law enforcement and resulted in successful criminal and civil prosecution and civil monetary penalties.

Medical Review Clinician position requires the individual to conduct complex medical record reviews and to apply sound clinical judgment to claim payment decisions. Responsibilities may include additional research on medical claims data and other sources of information to identify problems, review sophisticated data model output, and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. The incumbent will use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, over payment recovery. Will work with external agencies to develop cases and corrective actions as well as respond to requests for data and support.
Qualifications
Prerequisite:
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Current nursing license. Active license in California required.
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Three to five years of experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity.
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Strong communication and organization skills
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Strong investigative skills
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Strong Utilization Review
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Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
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Strong MS Word, Excel and Access knowledge
Essential Functions:
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Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
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Ability to research regulations and cite violations.
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Ability to conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers.
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Ability to make claim payment decisions based on clinical knowledge.
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Ability to compose correspondence, reports and referral summary letters.
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Ability to communicate effectively, internally and externally
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Ability to handle confidential material.
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Ability to report work activity on a timely basis.
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Ability to work independently and as a member of a team to deliver high quality work
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Ability to attend meetings, training, and conferences, overnight travel required
Educational Requirements
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Bachelor's degree or equivalent relevant work experience
Job - Services
Primary Location - United States-California-Chico

Schedule - Full-time
Job Type - Experienced
Shift - Day Job
Travel - Yes, 25 % of the Time

About this company
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Hewlett-Packard Company, or HP, is a multinational information technology corporation headquartered in Palo Alto, California, USA. HP got...