Nurse Specialist II

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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

• Perform medical record and claims review for Medicare, Medicaid, and/or other claims data • Ensure applicable guidelines have been followed and assess potential overpayment, fraud, waste, and abuse • Review beneficiary, provider, and/or pharmacy cases • Complete desk reviews or field audits to meet contract requirements and identify evidence of potential overpayment or fraud • Consult with benefit integrity investigation experts and pharmacists • Complete case summaries and provide results to investigators • Perform case-specific or plan-specific data entry and reporting • Participate in internal and external focus groups as required • Participate in provider onsite visits and beneficiary interviews for field audits/investigations as required • Testify at legal proceedings as necessary • Provide job-specific orientation and training • Help develop training content, resources, and programs • Plan and arrange own work with manager collaboration on project priorities

🎯 Requirements

• Minimum Bachelor's Degree required; education can be substituted for experience • 2–4 years of work 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 • Ability to perform medical record and claims review • Ability to complete desk reviews and field audits • Ability to conduct data entry and reporting • Ability to testify at legal proceedings as necessary • Successful completion of pre-employment background and drug screens required

🏖️ Benefits

• Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities • Drug-free workplace • Employment offers contingent upon successful completion of pre-employment background and drug screens