Medical Review Nurse- Medicare

Peraton•,

3d•$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 data and other information, reviewing sophisticated data-model output, and using tools to detect potential fraud and support investigations and information requests. The incumbent uses a variety of tools to develop cases for possible administrative action, including law-enforcement referrals, education, and overpayment recovery. The role also involves working with external agencies on cases and corrective actions, responding to requests for data and support, identifying and researching Medicare payment problems, and presenting concerns with citations to applicable regulations. Telework is available from anywhere in the United States. The position may require court testimony and overnight travel to attend meetings, training, and conferences.

Requirements

Five years of experience with a bachelor's degree (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 organizational skills.
Strong PC knowledge and skills.
U.S. citizenship.

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 apply clinical judgment to claim payment decisions.
Research medical claims data and other information to identify problems.
Review sophisticated data-model output and use tools to detect potential fraud and support investigations and information requests.
Develop cases for potential administrative action, including law-enforcement referral, 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, citing regulatory violations and alleged schemes to defraud the Government.
Research regulations and cite violations.
Conduct independent research to uncover problems in Medicare payments to institutional and non-institutional providers.
Make claim payment decisions based on clinical knowledge.
Compose correspondence, reports, and referral summary letters.
Communicate effectively internally and externally, handle confidential material, and report work activity in a timely manner.
Work independently and as part of a team to deliver high-quality work.
Attend meetings, training, and conferences; overnight travel is required.
Possibly appear in court to testify about work findings.