• Job Description

  Req#: 1037
  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 required
  
  Work Experience (can be substituted for education):
  2 - 4 years of experience required; 5 - 7 years preferred
  
  Certification(s):
  Current, active and non-restricted RN licensure required
  Coding certification preferred

• About the company

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