Claims Analyst III (Nurse Specialist III)

Claims Analyst III (Nursing Specialist III) Overview :

• J29 is an employee-centered healthcare management consulting company that specializes in processing, reviewing, and analyzing medical claims, records, disputes, and audits.
• Established in 2017, J29 prides itself on its employee-centric culture and high employee retention rates that allow us to ensure that we are creating a working environment that prioritizes the employee experience.
• Our team brings corporate performance that stretches to various areas where we can provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs at the State, Federal, and Commercial levels.  Job Summary Performs medical record and claims review for Medicare, Medicaid, and / or other claims data in order to ensure that proper guidelines have been followed and assesses for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and / or other claims.
• Key Responsibilities Reviews beneficiary, provider, and / or pharmacy cases for potential overpayment, fraud, waste, and abuse.
• Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
• Consults with benefit integrity investigation experts and pharmacists for advice and clarification.
• Completes case summaries and provides results to investigators to support the investigative process.
• Provides case specific or plan specific data entry and reporting.
• Participates in internal and external focus groups, as required.
• Participates in provider onsite visits and beneficiary interviews, as required, for field audits / investigations.
• Testifies at various legal proceedings, as necessary.
• Provides job-specific orientation and training, as needed.
• Helps develop training content, resources, and programs specific to job functions.
• Conducts medical review on a variety of service types.
• Provides clinical input as a Subject Matter Expert for the program integrity, medical review, and data teams.
• Requirements Requires 5-7 years work experience (this could be a combination of clinical and utilization review, case management, etc.) 8-11 years preferred.
• Must hold a current, active RN license issued by the state board of nursing.
• Compliance with all regulatory standards and ability to maintain licensure throughout employment is required.
• BSN degree is strongly preferred to ensure advanced clinical knowledge and leadership skills.
• Candidates with an Associate Degree in Nursing (ADN) will be considered if they demonstrate equivalent experience and commitment to continuing education.
• Coding certification preferred Demonstrates strong analytical skills and the ability to make sound, timely decisions.
• Proven ability to work effectively within diverse teams and foster a cooperative environment.
• Embraces continuous learning, adaptability, and supports the development of self and others.
• Skilled in planning, organizing, and delivering results while ensuring quality and support throughout processes.
• Proficient in using digital tools and technologies to enhance efficiency and communication.

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