Claims Analyst II - Medical Review RN - Medicare Part C

About the position The Claims Analyst II (Medical Review RN) role at Orchard LLC involves performing medical record and claims reviews for Medicaid/MCO and other claims data to ensure compliance with guidelines. This mid-level position is crucial in detecting and preventing fraud, waste, and abuse in the Medicare Part C program. The role requires strong analytical skills and the ability to evaluate medical claims data effectively, contributing to the overall integrity of healthcare delivery. Responsibilities • Review Explanation of Benefit (EOB) cases, beneficiary, provider, and pharmacy cases for potential overpayment, fraud, waste, and abuse. , • Complete desk reviews or field audits to meet contract requirements and identify evidence of potential fraud or overpayment. , • Identify and resolve claims issues, determining root causes effectively. , • Interact with beneficiaries and health plans to gather additional case-specific information as needed. , • Consult with Benefit Integrity investigation experts for advice and clarification. , • Complete inquiry letters, investigation finding letters, and case summaries. , • Investigate and refer all potential fraud leads to Investigators/Auditors. , • Perform case-specific or plan-specific data entry and reporting. , • Participate in internal and external focus groups and other projects as required. , • Identify opportunities to improve processes and procedures. , • Testify at various legal proceedings as necessary. , • Mentor and provide guidance to junior and level one analysts. Requirements • BSN or an RN with additional current and active degree/license/certification in a relevant healthcare discipline (e.g., CPC, CPHM, CFE, CCM, HCAFA), or willingness to obtain CPC. , • Current, active, and non-restricted RN licensure required. , • At least five years of clinical experience. , • At least one year of healthcare experience demonstrating expertise in utilization reviews. , • Strong understanding of ICD-9 coding, CPT coding, and Medicaid regulations preferred. , • Experience with Medicaid Utilization Management and understanding of hierarchies preferred. , • Prior experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred. , • Strong understanding of Excel. Nice-to-haves • Medicaid/MCO review experience strongly preferred. Benefits • Work from home opportunity within the continental United States. , • Full-time position with excellent benefits. Apply Job!