Nurse Specialist II

About Qlarant

Qlarant is a nonprofit organization that works alongside public and private partners to improve the quality, safety, and efficiency of health care and human services programs. Its work spans population health, utilization review, quality review for managed care organizations, and quality assurance for programs that support people with developmental disabilities. The company also serves as a national resource in combating fraud, waste, and abuse for major organizations across the United States. Through its Foundation, Qlarant also helps distribute grants to initiatives serving underserved communities.

Best People, Best Solutions, Best Results.

Role Summary

The Nurse Specialist II reviews medical records and claims tied to Medicare, Medicaid, and similar data sets to confirm that appropriate rules and guidelines were followed. The position also helps identify possible overpayments, fraud, waste, and abuse.

Key Duties

• Examine beneficiary, provider, and pharmacy-related cases to spot possible overpayments or signs of fraud, waste, and abuse.
• Carry out desk-based reviews or onsite audits in line with contract requirements and to gather evidence of possible overpayment or fraudulent activity.
• Work with benefit integrity investigation specialists and pharmacists to clarify issues and obtain guidance.
• Prepare concise case summaries and share findings with investigators to support ongoing inquiries.
• Enter case-specific or plan-specific information and produce related reports.
• Take part in internal or external focus groups when needed.
• Join provider site visits and beneficiary interviews for field audits or investigations when required.
• Provide testimony in legal proceedings when necessary.
• Deliver orientation and job-specific training as needed, and assist in creating training materials, resources, and programs related to the role.

Work Style and Supervision

The role requires a self-managed approach. The incumbent plans their own work and coordinates with management to prioritize assignments.

Education and Experience

A bachelor’s degree is required, though relevant experience may be considered in place of education. Candidates should have 2 to 4 years of experience, with 5 to 7 years preferred. Experience in medical review or utilization management is preferred, and Medicare/Medicaid experience is also preferred.

Licensing and Certification

An active, current, and unrestricted RN license is required. A coding certification is preferred.

Additional Employment Terms

Qlarant is an equal opportunity employer and considers applicants without regard to minority status, gender, protected veteran status, or disability. The organization maintains a drug-free workplace. All employment offers depend on successful completion of background screening and drug testing before hire.