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Job Title
Medical Review Nurse (BOS) - Home-based - Nationwide Openings


Job Description
Utilize your claims review experience to make a difference in the future of the Medicare and Medicaid programs! In anticipation of future contract award, Health Integrity is seeking experienced Medical Review RN's for multiple home-based positions throughout the continental U.S. Why join the Health Integrity team? As a Medical Review RN, you will play a key role in protecting Medicare and Medicaid services from fraud, waste and abuse. In addition, we offer a collaborative work environment, opportunities for advancement and an excellent benefits package that includes two retirement plans. PLEASE NOTE: This position is contingent upon contract award. This is not an immediate opening.
The Medical Review Nurse - Claims Analyst is a mid-level professional performing medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed. This position works in a fast-paced, high volume environment that requires a strong sense of urgency, ability to work independently, and detail orientation.
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.
Health Integrity, a wholly-owned subsidiary of Quality Health Strategies, Inc., is dedicated to protecting the fiscal and clinical integrity of healthcare systems in Medicare, Medicaid, and the private sector. The company operates nationally as a federally-designated program integrity contractor for the Centers for Medicare & Medicaid Services (CMS). Health Integrity’s expert clinical and technical staff identify and investigate potential fraud, waste and abuse in healthcare – aiding law enforcement agencies and protecting public resources.
Required Skills
To perform the job successfully, an individual should demonstrate the following competencies:
- 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.
- 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.
- 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.
- 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.
Required Experience
A 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. Knowledge of Medicare sufficient to perform in-depth claims review. At least one year healthcare experience that demonstrates expertise in conducting utilization reviews, ICD-9 coding, and CPT coding strongly preferred. Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred. Experience working remotely preferred.
PLEASE NOTE: This position is contingent upon contract award. This is not an immediate opening.
Certificates, Licenses, Registrations
Current, active and non-restricted RN licensure required.
Health Integrity is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.
Job Location
Boston, Massachusetts, United States
Position Type

Last verified - 1 day(s) 16 hour(s) ago   [What does Last Verified mean?]

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