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