Medical Review Nurse - Medicare/Medicaid Audit
Cerritos, CA 
Posted Today
Job Description
Medical Review Nurse - Medicare/Medicaid Audit

Job Location
Cerritos, CA

Position Type

Qlarant, Inc., 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're a national leader in fighting fraud, waste and abuse for large organizations across the country.

Qlarant has exciting opportunity for a Registered Nurse with MR/UR experience, strong Medicare/Medicaid knowledge and investigative skills to join our Cerritos, CA based Unified Program Integrity Contractors (UPIC) team. Our UPIC team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 16 Western states and territories. We're seeking candidates that possess strong analytical skills in addition to their clinical experience. Well qualified candidates should possess a sense of urgency and a track record of exceeding expectations.

The selected candidate can be based in our Cerritos, CA office or home-based within the UPIC Western jurisdiction (Arizona, California, Nevada, Utah, Oregon, Washington, Idaho, North Dakota, South Dakota, Wyoming, Montana, Alaska and Hawaii). In addition to a competitive compensation package, Qlarant offers excellent benefits that include two pension plans and generous vacation and sick leave accruals.

Please Note: Current, active and non-restricted RN license required. An LVN will not meet CMS requirements.

This is a mid-level professional position that works both independently and in a team environment that may be comprised of medical professionals, claims analysts, and auditors to perform medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed, as well as production of final review/audit report across all service and provider types, including, but not limited to, individual practitioners, institutions, and managed care entities to examine payments to providers. Where payments are not valid, establishes overpayments and initiates recoupment, revocation, or other administrative actions, as appropriate.

Primary duties include:

  • Review Explanation of Benefit (EOB) cases, beneficiary, provider, and other potential overpayment, fraud, waste, and abuse.
  • Completes desk review or field review/audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
  • Effectively identifies and resolves claims issues and determines root cause.
  • Interacts with beneficiaries and health plans to obtain additional case specific information, as needed.
  • Consults with Subject Matter Experts for advice and clarification.
  • Completes inquiry letters, investigation finding letters, and case summaries.
  • Gathers necessary citations to document review/audit findings.
  • Coordinates review/audit activities with appropriate staff.
  • Prepares work-papers timely and places them in the appropriate files.
  • Uses the quality review process effectively to ensure final review/audit reports are error free.
  • Completes review/audits and auditing steps within established timeframes and using established auditing principles, proactively informing management of potential shortfalls in timeliness and quality.
  • Performs research regarding Medicare and Medicaid guidelines, to be well versed about rules, regulations, and policies that will be needed to establish incorrect payments to providers and identify overpayments for recovery.
  • Identifies potential fraud independently and refers matters of fraud to the CMS-MIG and law enforcement, as prescribed.
  • Responsible for case-specific or plan-specific data entry and reporting.
  • Participates in internal and external focus groups and other projects, as required.
  • Identifies opportunities to improve processes and procedures.
  • Testifies at various legal proceedings, as necessary.
  • May mentor and provide guidance to junior associates.
  • Performs a variety of tasks some requiring independent thought and research. A degree of creativity and latitude is required.
  • Serves as a trainer or staff resource for technical and program issues.
  • Uses and handles Personally Identifiable Information (PII) and Personal Health Information (PHI) in a manner consistent with corporate policies, government regulations and laws. If PII and PHI is mishandled or released inappropriately, disclosure protocols must be followed.

Required Skills

Language Skills

  • Ability to read, analyze, and interpret technical procedures, review documents, or contract regulations.
  • Ability to write reports, business correspondence, and procedures.
  • Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public. Communicates professionally with internal and external stakeholders.

Mathematical Skills

  • Ability to apply basic mathematical functions.

Reasoning Ability

  • Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
  • Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Other Skills and Abilities

  • To perform this job successfully, an individual should have basic understanding of the use of the computer for entry and research and knowledge of office software to include Microsoft Office applications and the internet to meet contract deliverables.
  • Utilizes required data entry and reporting systems, including advanced features.
  • Must have the ability to work independently with minimal supervision.
  • Must be able to communicate effectively with all members of the team to which he/she is assigned.
  • Must have the ability to grasp and adapt to changes in procedure and process.
  • Must have the ability to effectively resolve complex issues.
  • Ability to organize work activities in order of ever-changing priorities, ensuring that critical paths and due dates are met.

Required Experience
  • A BSN or an RN with additional current and active degree/license/certification/s in a relevant discipline (i.e., CPC, CPHM, CFE, CCM, HCAFA, Finance, Accounting).
  • At least five years clinical experience. At least two years claims review experience required.
  • Experience that demonstrates expertise in conducting utilization reviews, ICD-9/10 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations preferred.
  • Certified professional coding credentials preferred (or will be required within one year of hire).
  • Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.
  • Pre- and post-pay claims review and healthcare data experience preferred.
  • Current, active and non-restricted RN license required. An LVN only will not meet requirements.

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, Sexual Orientation, Gender Identity, and Individuals with Disabilities. Best People, Best Solutions, Best Results


Job Summary
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Experience
5+ years
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