Medical Review Nurse

Peraton•,

1d•$66,000 - $106,000•Remote

About The Position

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse. We are looking to add a Nurse Reviewer to our SGS team of talented professionals. The position requires the individual to conduct medical record reviews and to apply sound clinical judgment to claim payment decisions. Responsibilities may include additional research on medical claims data and other sources of information to identify problems, review sophisticated data model output, and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. The incumbent will use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, and overpayment recovery. Will work with external agencies to develop cases and corrective actions as well as respond to requests for data and support. Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government. Research regulations and cite violations. Conduct self-directed research to uncover problems in Medicaid payments made to institutional and non-institutional providers. Make claim payment decisions based on clinical knowledge. Telework available in the contiguous United States.

Requirements

7 years with AS/AA; 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD
Proven experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of 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
US citizenship required

Nice To Haves

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

Responsibilities

Conduct medical record reviews and apply sound clinical judgment to claim payment decisions.
Conduct additional research on medical claims data and other sources of information to identify problems.
Review sophisticated data model output.
Utilize a variety of tools to detect situations of potential fraud and to support ongoing fraud investigations and requests for information.
Identify and develop cases for future administrative action, including referral to law enforcement, education, and overpayment recovery.
Work with external agencies to develop cases and corrective actions.
Respond to requests for data and support.
Present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government.
Research regulations and cite violations.
Conduct self-directed research to uncover problems in Medicaid payments made to institutional and non-institutional providers.
Make claim payment decisions based on clinical knowledge.
Appear in court to testify to work findings.
Compose correspondence, reports, and referral summary letters.
Communicate effectively, internally and externally.
Handle confidential material.
Report work activity on a timely basis.
Work independently and as a member of a team to deliver high quality work.
Attend meetings, training, and conferences.