Nurse

Job Title

Job Description

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Apply a wide range of software, systems, and analytical platforms to identify overpayments and detect fraud/abuse across Medicare, Medicaid, and the Children's Health Insurance Program (CHIP).

Develop algorithms/models, conducting data mining, and providing clinical and analytical decision support to improve the efficiency and effectiveness of program integrity operations.

Review Federal laws, regulations, and procedural guidelines to advise leadership on technical flaws and regional impacts of proposed policy changes.

Develop guidelines and procedures for reviewing clinical data to determine whether beneficiaries are receiving medically necessary care at appropriate levels of service.

Utilize nursing expertise to refine or develop implementing regulations and methods for addressing healthcare coverage and payment determinations.

Maintain a comprehensive outreach/education program to ensure Medicare contractors, beneficiaries, families, Congressional representatives, and community-based partners are informed of program benefits, rights, and responsibilities.

Determine training needs, develop/conduct regional training for Medicare contractor staff, and serve as a Business Functional Lead, Contracting Officer's Representative (COR), or Government Task Lead (GTL) over contracts and task orders.

Represent CMS at meetings, seminars, conferences, and before health organizations, professional panels, and special interest groups on issues related to program vulnerabilities, fraud/abuse detection, and clinical nursing concerns.

Speak on behalf of CMS leadership, prepare/present papers, briefing materials, and findings to promote understanding and acceptance of Agency policies at both the regional and national level.