Claims Analyst II - Medical Review RN - Medicare Part C - 27744410-5296

About the position

The Claims Analyst II - Medical Review RN position at Orchard LLC involves evaluating medical claims data to detect and prevent fraud, waste, and abuse in the Medicare Part C program. This mid-level role requires strong analytical skills and the ability to perform medical record and claims reviews, ensuring compliance with guidelines. The position is home-based and full-time, offering excellent benefits.

Responsibilities
• 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.
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• Complete desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
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• Effectively identify and resolve claims issues and determine root cause.
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• Interact with beneficiaries and health plans to obtain 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 the 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 (i.e., 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 clinical experience.
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• At least one year of healthcare experience that demonstrates expertise in utilization reviews.
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• Strong understanding of Excel.

Nice-to-haves
• Medicaid/MCO review experience strongly preferred.
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• ICD-9 coding, CPT coding, and knowledge of Medicaid regulations strongly preferred.
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• Experience with Medicaid Utilization Management with understanding of how to apply hierarchies preferred.
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• Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.

Benefits
• Work from home within the Continental United States
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• Excellent benefits package

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