Insurance / Healthcare Iii - (US-PA-Camp Hill - 17089)

Minimum Education: None
Job Type: Full Time
Jobcode: N/A
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Responsibilities: This position is to support Medicare Systems in a Nurse Investigator/Reviewer role. The responsibilities of this role are to conduct medical record reviews and to apply sound clinical judgment to claim payment decisions. Responsibilities may include additional research on medical claims data and other sources of information to identify problems, review sophisticated data model output, and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. The incumbent will use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, over payment recovery. Will work with external agencies to develop cases and corrective actions as well as respond to requests for data and support. This position is for the Eastern Benefit Integrity Support Center (BISC) Contract. The mission of this contract is to detect and deter fraud and abuse in the Medicare Program for Part A and B New York and New Jersey. Prerequisites: Current nursing license - RN Strong investigative skills Strong communication and organization skills Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases preferred Strong PC knowledge and skills Essential Functions: Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government Ability to research regulations and cite violations. Ability to conduct self-directed research to uncover problems in Medicare payments made to institutional and non- institutional providers. Ability to make claim payment decisions based on clinical knowledge. Ability to compose correspondence, reports and referral summary letters. Ability to communicate effectively, internally and externally Ability to handle confidential material. Ability to report work activity on a timely basis. Ability to work independently and as a member of a team to deliver high quality work Ability to attend meetings, training, and conferences, overnight travel required Career Path: Individual performer roles with increased levels of responsibility, complexity of work or leadership roles are available based on performance.Capabilities: Project SupportIndustry: Government Position Prerequisites:SRF Type: External Immediately Business need: Current Future Position: NO Subcontractor Eligible: NO Service Contact Act applicable: NO Clearance requirements: None Degree needed: Registered Nurse (RN) Minimum of three to five years experience in the medical field as a registered nurse. Nurse Investigator/Reviewer - This position is to support Medicare Systems in a Nurse Investigator/Reviewer role. The responsibilities of this role are to conduct medical record reviews and to apply sound clinical judgment to claim payment decisions. Responsibilities may include additional research on medical claims data and other sources of information to identify problems, review sophisticated data model output, and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. The incumbent will use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, over payment recovery. Will work with external agencies to develop cases and corrective actions as well as respond to requests for data and support. This position is for the Eastern Benefit Integrity Support Center (BISC) Contract. The mission of this contract is to detect and deter fraud and abuse in the Medicare Program for Part A and B New York and New Jersey. Prerequisites: Current nursing license - RN Strong investigative skills Strong communication and organization skills Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases preferred Strong PC knowledge and skills..

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