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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