Utilization Review Nurse

• Contract through end of year, with possible extension
• Will be required to obtain a Public Trust Clearance

We are seeking a Clinical Review Nurse ideally with hospice/home health review experience to support a UPIC (Unified Program Integrity Contractor) contract to support the Centers for Medicare & Medicaid Services (CMS) by investigating healthcare fraud, waste, and abuse.

Responsibilities

• Reviews beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse.
• Completes desk review to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
• Completes case summaries and provides results to investigators to support the investigative process.
• Provides case specific or plan specific data entry and reporting.

Requirements

• Active non-restricted RN licensure.

Preferred

• Coding certification
• Medical chart review, varied clinical background
• Hospice/Home Health review / background would be very beneficial

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