Nurse Specialist II

🕒 May 27

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Qlarant

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1973

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Qlarant is a US-based services and technology firm specializing in healthcare program integrity, offering quality improvement, fraud, waste & abuse (FWA) detection and investigative services, and advanced data analytics and predictive modeling tools (the RIViR® Risk Solution Suite) for government agencies, health plans, and related sectors. The company also operates initiatives like the Qlarant Foundation and Qlarant Capital to fund grants and early-stage startups, and provides pharmacy, drug pricing, and transportation-focused solutions.

📋 Description

• Performs medical record and claims review for Medicare, Medicaid, and/or other claims data • 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 • Consults with benefit integrity investigation experts and pharmacists for advice and clarification • Completes case summaries and provides results to investigators • 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

🎯 Requirements

• Minimum Bachelor's Degree required • 2 - 4 years of experience required; 5 - 7 years preferred • Medical claims review experience required • Experience and knowledge of Medicare/Medicaid preferred • Current, active and non-restricted RN licensure required • Coding certification preferred