RN Claims Analyst I - Part-time
Location: Easton, Maryland
Description: Delmarva Foundation, Inc. is employing RN Claims Analyst I - Part-time right now, this vacancy will be assigned in Maryland. Further informations about this vacancy opportunity kindly read the description below. Are you a Registered Nurse looking for flexible hours, interesting work, excellent benefits, and very competitive compensation? Health Integrity, a highly successful not-for-profit with a passion for excellence is seeking a part-time RN Claims Analyst I for our Easton headquarters.
This entry level professional position performs medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed. As a member of an investigative team, the Claims Analyst I may act as a facilitator as well as a case manager regarding assessment for potential overpayment, fraud, waste, and abuse with regards to Medicare Parts C & D, Medicaid, and/or other claims. Essential duties and
responsibilities include:
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.
Completes desk review audits to ensure completeness and to identify evidence of potential overpayment or fraud.
Effectively identifies and resolves claims issues and determines root cause. Interacts with beneficiaries, health plans, and medical service providers to obtain additional case specific information, as needed.
Consults with Benefit Integrity investigation experts and pharmacists for advice and clarification.
Completes inquiry letters, investigation finding letters and case summaries.
Investigates and refers all potential fraud leads to the Investigators. Has basic understanding of the use of the desktop computer for entry and research.
Responsible for case specific or plan specific data entry and reporting.
Participates in internal and external focus groups, as required.Identifies opportunities to improve processes and procedures.
Has the responsibility and authority to perform their job and provide customer satisfaction.
May participates as an audit/investigation team member for both desk and field audits/investigations.
Familiar with commonly used concepts, practices and procedures, relying on instructions and pre-established guidelines to perform the functions of the job.
Requirements
Education and/or Experience
A LVN or RN diploma/license or other licensure in a relevant healthcare discipline is required.
Must possess one to two years clinical experience in health care claims that demonstrates expertise in reading utilization reviews, ICD-9 coding, CPT coding, and interpreting Medicare or Medicaid claims data.
Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.
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If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to Delmarva Foundation, Inc..
Interested on this vacancy, just click on the Apply button, you will be redirected to the official website
This vacancy starts available on: Mon, 23 Jul 2012 21:52:01 GMT
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