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.
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?? Complete desk reviews or field audits to meet contract requirements and identify evidence of potential fraud or overpayment.
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?? Identify and resolve claims issues, determining root causes effectively.
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?? Interact with beneficiaries and health plans to gather additional case-specific information as needed.
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?? Consult with Benefit Integrity investigation experts for advice and clarification.
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?? Complete inquiry letters, investigation finding letters, and case summaries.
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?? Investigate and refer all potential fraud leads to Investigators/Auditors.
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?? Perform case-specific or plan-specific data entry and reporting.
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?? Participate in internal and external focus groups and other projects as required.
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?? Identify opportunities to improve processes and procedures.
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?? Testify at various legal proceedings as necessary.
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?? 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.
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?? Current, active, and non-restricted RN licensure required.
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?? At least five years of clinical experience.
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?? At least one year of healthcare experience demonstrating expertise in utilization reviews.
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?? Strong understanding of ICD-9 coding, CPT coding, and Medicaid regulations preferred.
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?? Experience with Medicaid Utilization Management and understanding of hierarchies preferred.
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?? Prior experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.
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?? Strong understanding of Excel.

Nice-to-haves
?? Medicaid/MCO review experience strongly preferred.

Benefits
?? Work from home opportunity within the continental United States.
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?? Full-time position with excellent benefits.

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