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. , • Complete desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud. , • Effectively identify and resolve claims issues and determine root cause. , • Interact with beneficiaries and health plans to obtain 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 the 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 (i.e., CPC, CPHM, CFE, CCM, HCAFA), or willingness to obtain CPC. , • Current, active, and non-restricted RN licensure required. , • At least five years clinical experience. , • At least one year of healthcare experience that demonstrates expertise in utilization reviews. , • Strong understanding of Excel. Nice-to-haves • Medicaid/MCO review experience strongly preferred. , • ICD-9 coding, CPT coding, and knowledge of Medicaid regulations strongly preferred. , • Experience with Medicaid Utilization Management with understanding of how to apply hierarchies preferred. , • Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred. Benefits • Work from home within the Continental United States , • Excellent benefits package Apply Job! Apply tot his job