Medical Review Analyst

Peraton•,

2d•$51,000 - $82,000•Remote

About The Position

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, and reduce fraud, waste, and abuse, and to make referrals for recovery. The Medical Review Analyst (described in the posting as a Nurse Reviewer) conducts medical record reviews and applies sound clinical judgment to claim payment decisions. The role may involve researching medical claims data and other information, reviewing sophisticated data-model output, and using tools to detect potential fraud and support investigations and requests for information. The analyst helps develop cases for administrative action, law-enforcement referral, education, and overpayment recovery; works with external agencies on cases and corrective actions; and responds to data and support requests. The position is available for telework from anywhere in the United States and may require court testimony and overnight travel.

Requirements

At least 5 years of experience with a BS/BA.
Experience in the medical field as a Registered Nurse or other clinician, and/or experience reviewing medical claims for coverage and medical necessity.
Current nursing license.
Strong investigative skills.
Strong communication and organization skills.
Ability to apply Federal, State, and Managed Care Organization (MCO) regulations to claims under review.
Strong PC knowledge and skills.
U.S. citizenship.
Ability to handle confidential material and report work activity on a timely basis.
Ability to work independently and as a member of a team.

Nice To Haves

Experience reviewing claims for technical requirements, performing medical review, and/or developing fraud cases.
Experience working on cases involving services performed for Medicaid.
Certified Professional Coder (CPC) certificate.

Responsibilities

Conduct medical record reviews and make claim payment decisions using clinical knowledge and judgment.
Research medical claims data and other information to identify problems, including Medicaid payment issues involving institutional and non-institutional providers.
Review data-model output and use tools to identify potential fraud and support fraud investigations and information requests.
Identify and develop cases for administrative action, law-enforcement referral, education, and overpayment recovery.
Present issues of concern and cite regulatory violations, including alleged schemes or scams to defraud the Government.
Research regulations and cite violations.
Work with external agencies to develop cases and corrective actions, and respond to data and support requests.
Compose correspondence, reports, and referral summary letters.
Communicate effectively with internal and external stakeholders, handle confidential material, and report work activity on time.
Work independently and as part of a team; attend meetings, training, and conferences, with overnight travel required.
Appear in court to testify about work findings when required.