Medical Review Nurse- Medicare

Peraton•,

1d•$51,000 - $82,000•Remote

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 make referrals for recovery. The Nurse Reviewer conducts medical-record reviews and applies sound clinical judgment to claim-payment decisions. The role may involve researching medical claims and other information, reviewing sophisticated data-model output, and using tools to identify potential fraud and support investigations and requests for information. The reviewer develops cases for administrative action, including law-enforcement referrals, education, and overpayment recovery; works with external agencies on cases and corrective actions; and responds to requests for data and support. The position is available for telework from anywhere in the United States and may require overnight travel and court testimony.

Requirements

Two years of experience with a bachelor's degree, four years with an associate degree, or six years with a high school diploma or equivalent.
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 organizational skills.
Strong PC knowledge and skills.
U.S. citizenship.
Ability to compose correspondence, reports, and referral summary letters; communicate effectively; handle confidential material; report work activity promptly; and work independently and collaboratively.
Ability to attend meetings, training, and conferences, with overnight travel required.
Ability to appear in court to testify about work findings when 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 based on clinical knowledge.
Research medical claims data and other sources to identify problems, including conducting self-directed research into Medicare payments to institutional and non-institutional providers.
Review sophisticated data-model output and use tools to detect potential fraud and support investigations and information requests.
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 issues of concern, cite regulatory violations, and describe alleged schemes or scams to defraud the Government.
Research regulations and cite violations.
Compose correspondence, reports, and referral summary letters.
Communicate effectively with internal and external contacts and handle confidential material.
Report work activity in a timely manner and work independently or as part of a team to deliver high-quality work.
Attend meetings, training, and conferences, with overnight travel required.
Appear in court to testify about work findings when required.