Nurse Specialist II

About the role

Qlarant is seeking a Nurse Specialist II to perform medical record and claims reviews for Medicare, Medicaid, and other programs. The role focuses on identifying potential overpayments, fraud, waste, and abuse while supporting investigative processes. This position works closely with benefit integrity experts, pharmacists, and investigators.

Key responsibilities

• Review beneficiary, provider, and pharmacy cases for signs of overpayment, fraud, waste, and abuse.
• Conduct desk reviews and field audits to meet contract requirements and uncover evidence of improper payments.
• Collaborate with benefit integrity investigators and pharmacists for guidance and clarification.
• Prepare case summaries and deliver findings to support investigations.
• Enter case‑specific data and generate reports as required.
• Participate in internal and external focus groups, provider onsite visits, and beneficiary interviews.
• Testify in legal proceedings when necessary.
• Provide orientation, training, and assist in developing training materials for the role.

Required profile

• Current, active, and unrestricted RN licensure.
• Bachelor’s degree (minimum) or equivalent experience.
• 2–4 years of medical claims review experience (5–7 years preferred).
• Experience with Medicare and Medicaid programs is preferred.
• Strong analytical and investigative abilities.

Required skills

• Medical coding