Position Overview:
The position requires the Registered Nurse 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 and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. The Registered Nurse will work with PHS leadership, in concert with our clients, to review cases and produce a concise and accurate summary of determinations. The Registered Nurse will comply with the PHS policies related to Conflict of Interest and Compliance and will abide by the PHS Code of Conduct.
Prerequisite:
- Current Oklahoma Registered Nursing license and not listed on the OIG Excluded Individual database
- Two years of experience in the medical field as a Registered Nurse. May substitute one year of clinical experience for experience in review of medical claims for coverage and medical necessity
- Demonstrated history of professional conduct and success in working independently and as a member of a team
- Strong interpersonal skills
- Strong critical thinking and investigative skills
- Strong verbal and written communication and organization skills
- Strong computer knowledge and skills, including Microsoft Word and Excel programs
Essential Functions:
- Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
- Ability to gather information systematically to establish facts
- 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 medical review summary reports and correspondence concisely and accurately
- Ability to communicate effectively, internally and externally
- Ability to handle PHI and ePHI in a secure and confidential manner
- 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 and education offerings.
- Ability to manage time effectively, prioritizing tasks and able to meet deadlines
Job Type: Full-time
Pay: $32.50 - $34.00 per hour
Benefits:
- Dental insurance
- Health insurance
- Vision insurance
Education:
Experience:
- Nursing: 2 years (Required)
License/Certification:
- Registered Nurse (Required)
- RN (Required)
Location:
- Oklahoma City, OK (Required)
Work Location: Remote
