Pre-Payment Review Nurse Consultant

🔥 0 minutes ago

🧀 Wisconsin – Remote

🧀 Wisconsin – Remote

💵 $86k - $105k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Healthcare Insurance • Human Services • Healthcare

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Conducting clinical and financial pre-payment compliance reviews to detect, combat, and eliminate fraud, waste, and abuse in the Medicaid program. • Consulting on the development and implementation of pre‑payment review policies and guidelines that support OIG program objectives. • Perform comprehensive medical record reviews and analyze complex datasets and systems. • Develop, establish, and implement pre‑payment review criteria across multiple service areas. • Process pre‑payment reviews according to medical necessity criteria, administrative code, and other requirements.

🎯 Requirements

• Current Wisconsin Registered Nurse license issued by the Wisconsin Department of Safety and Professional Services. • Knowledge of current medical concepts, practices, and techniques. • Ability to assess statistical data and reports related to health service utilization patterns. • Knowledge of laws, statutes, regulations, and rules related to the state Medicaid program. • Knowledge of federal and state legislation pertaining to Title XIX, Title XVIII, Title XX, and Title III. • Ability to incorporate medical knowledge and experience into the development of medical policy, administrative rules, and medical standards. • Ability to develop standards and guidelines for monitoring medical practice patterns. • Thorough knowledge of Medicaid-covered services and reimbursement policy for analysis, recommendation development, and implementation. • Ability to use medical and financial records, claims, and claims data to obtain documentation supporting audit or investigative findings. • Knowledge of Generally Accepted Auditing Standards (GAAS). • Skill in using computer-accessible databases to support audit activities and technology used for pre-payment review audits, including reviewing and analyzing computer-generated reports. • Extensive knowledge of hardware, software, and networking technologies relevant to healthcare industry changes. • Knowledge of program, financial, and accounting systems used by healthcare entities, including patient account management, billing processes, and reimbursement procedures. • Understanding of governmental and industry accounting and auditing standards or audit guides used to audit healthcare providers. • Ability to organize, prepare, summarize, and present information gathered during audits or investigations in a clear and usable manner to support valid findings and conclusions. • Extensive knowledge of technical writing, publication organization, preparation, and formatting. • Ability to clearly express the State’s position on Medicaid issues—both orally and in writing—in audit reports, investigative reports, exit conferences, and departmental meetings. • Knowledge of records maintained by healthcare providers and the ability to inspect medical records, patient charts, financial statements, transaction documentation, invoices, payroll records, and claims.

🏖️ Benefits

• generous, flexible vacation policy • 401(k) employer match • comprehensive health benefits • educational assistance • leadership and technical development academies