Medical Review Analyst - Medicare
About The Position
SafeGuard Services (SGS), a subsidiary of Peraton, conducts data analysis, investigations, and medical reviews to detect, prevent, deter, and reduce fraud, waste, and abuse, and to support recovery referrals. The Medical Review Analyst conducts medical record reviews and applies sound clinical judgment to claim payment decisions. The role includes researching claims data and other information, reviewing sophisticated data-model output, and using tools to identify potential fraud and support investigations and requests for information. The analyst develops cases for potential administrative action, including law-enforcement referrals, education, and overpayment recovery, and works with external agencies on cases, corrective actions, and data requests. Telework is available from the contiguous United States. Overnight travel is required, and the position may require court testimony about work findings.
Requirements
- Five years of experience with a BS/BA, three years with an MS/MA, or zero years with a PhD.
- Experience in the medical field as a Registered Nurse or other clinician, and/or experience reviewing medical claims for coverage and medical necessity.
- Current, active Nursing or Physical Therapy license.
- Strong investigative skills.
- Strong communication and organizational skills.
- Strong PC knowledge and skills.
- U.S. citizenship required.
- Ability to communicate effectively internally and externally.
- Ability to handle confidential material and report work activity in a timely manner.
- Ability to work independently and as a member of a team.
- Ability to attend meetings, training, and conferences; overnight travel is required.
Nice To Haves
- Experience reviewing claims for technical requirements, performing medical review, and/or developing fraud cases.
- Certified Professional Coder (CPC) certificate.
Responsibilities
- Conduct medical record reviews and make claim payment decisions using clinical knowledge.
- Research claims data, regulations, and other sources to identify problems in Medicare payments to institutional and non-institutional providers.
- Review data-model output and use tools to detect potential fraud and support investigations and requests for information.
- Identify and develop cases for administrative action, including law-enforcement referrals, education, and overpayment recovery.
- Work with external agencies to develop cases and corrective actions and respond to requests for data and support.
- Present concerns, cite regulatory violations, and identify alleged schemes or scams to defraud the Government.
- Compose correspondence, reports, and referral summary letters.
- Handle confidential material and report work activity in a timely manner.
- Work independently and as part of a team; attend meetings, training, and conferences.
- Appear in court to testify about work findings when required.
Benefits
- Medical, dental, and vision benefits.
- Life insurance.
- Health savings account.
- Short- and long-term disability.
- Employee assistance program (EAP).
- Parental leave.
- 401(k).
- Paid time off for vacation.
- Company-paid holidays.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
