Medical Review RN - MIC
Location: Easton, Maryland
Description: Delmarva Foundation, Inc. is looking of Medical Review RN - MIC right now, this position will be reside in Maryland. For complete informations about this position opportunity please read the description below. Medical Review RN - Claims
Analyst II - MIC
Health Integrity LLC, a highly
successful not-for-profit company with a passion for excellence, is
seeking experienced and ! motivated Medical Review RN
candidates for an opening at our Easton, MD
headquarters.
Essential Duties and
Responsibilities include, but are not limited to, some or
all of the following: ·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
- Consults with Benefit Integrity investigation experts and
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 participate as an
audit/investigation team member for both desk and field
audits/investigations. ·Has developed expertise with standard
concepts, practice and procedures in field. Relies on limited
experience and judgment to plan and accomplish goals. ·May mentor and
provide guidance to junior and level one analysts. ·Performs a
variety of tasks some requiring independent thought and research. A
degree of creativity and latitude is required.
Requirements
A BSN or an RN with
additional degree/licens! ure/certification in a relevant healthcare
discipline (i.e., CPC, CCM, CFE). Must possess at least five years
acute care clinical experience. One to two years healthcare
experience that demonstrates expertise in conducting utilization
reviews, ICD-9 coding, CPT coding, and knowledge of Medicare and/or
Medicaid regulations preferred. Prior successful experience with CMS,
State Medicaid, and OIG/FBI or similar agencies preferred.
About Health
Integrity
Health Integrity, LLC, a wholly owned
subsidiary of Quality Health Strategies, is responsible for
performing benefit integrity tasks for CMS related to multiple
Medicare and Medicaid contracts by monitoring complaints and
initiating fraud investigations for referral to the Office of
Inspector General (OIG) as well as supporting cases with data,
medical and pharmaceutical experience, audits, training and
investigative expertise.
We offer you:
Excellent company paid benefits, including
parking;
! Flexible weekday hours with holidays off;
Interesting and challenging work;
A stimulating work environment; and
The chance to join a team in making a positive
difference.
For more information about Health Integrity, please visit our
website at: http://www.healthintegrity.org
/ .
Affirming equal opportunity in
principle and practice, Health Integrity is an equal opportunity
employer, committed to developing a diverse workforce.
- .
If you were eligible to this position, please give us your resume, with salary requirements and a resume to Delmarva Foundation, Inc..
Interested on this position, just click on the Apply button, you will be redirected to the official website
This position will be started on: Sun, 24 Mar 2013 15:41:33 GMT
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