Medical Review Nurse- Medicare

Peraton•,

7d•$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 support recovery referrals. The Medical Review Nurse conducts medical record reviews and applies clinical judgment to claim payment decisions. The position also involves researching medical claims data and other information, reviewing data-model output, and using tools to identify potential fraud and support investigations and information requests. The Nurse Reviewer develops cases for administrative action, including referrals to law enforcement, education, and overpayment recovery; works with external agencies on cases and corrective actions; and responds to requests for data and support. The role is available for telework from anywhere in the United States and may require overnight travel and court testimony.

Requirements

Five years of experience with a bachelor's degree, or seven years of experience with an associate degree.
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.
Strong PC knowledge and skills.
U.S. citizenship.
Ability to compose correspondence, reports, and referral summary letters.
Ability to handle confidential material and report work activity on a timely basis.
Ability to work independently and as a member of a team.
Ability to attend meetings, training, and conferences, with overnight travel 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 apply sound clinical judgment to claim payment decisions.
Research medical claims data and other sources of information to identify problems.
Review sophisticated 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 issues of concern, citing regulatory violations and alleged schemes or scams to defraud the Government.
Research regulations and cite violations.
Conduct self-directed 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 with internal and external audiences, 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; travel overnight as required.
Appear in court to testify about work findings when required.

Benefits

Medical benefits
Dental insurance
Vision insurance
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
Potential eligibility for overtime, shift differential, and a discretionary bonus