Nurse Reviewer: Investigations Part C

Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.

Best People, Best Solutions, Best Results

Job Summary:

Performs medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed and assesses for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and/or other claims.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Reviews beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse.
• Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
• Consults with benefit integrity investigation experts and pharmacists for advice and clarification.
• Completes case summaries and provides results to investigators to support the investigative process.
• Provides case specific or plan specific data entry and reporting.
• Participates in internal and external focus groups, as required.
• Participates in provider onsite visits and beneficiary interviews, as required, for field audits/investigations.
• Testifies at various legal proceedings, as necessary.
• Provides job-specific orientation and training, as needed. Helps develop training content, resources, and programs specific to job functions.

To perform the job successfully, an individual should demonstrate the following competencies:

• Business Expertise- Good understanding of how the team integrates with others in accomplishing the objectives of the department.
   
• Problem Solving- Uses judgment based on practice and precedence.
   
• Nature of Impact- Small, but direct impact through the quality of the tasks/service provided by the individual.
   
• Area of Impact- Primarily on closely related departments.
   
• Interpersonal Skills- Developed communication skills to exchange complex information.
   
• Leadership- No supervisory responsibility, but the job provides on-the-job training/support to new team members.
   
• Functional Knowledge- Good understanding of concepts and procedures within own discipline and basic knowledge of these elements in other disciplines.
   
• Project Management- Project/program team member.