Nurse Reviewer - Medicaid

Peraton•,

5d•$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 Medical Reviewer to our SGS team of talented professionals. The Medical Reviewer 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, over payment recovery. Will work with external agencies to develop cases and corrective actions as well as respond to requests for data and support.

Requirements

Bachelors and 5 years of experience, Masters degree and 3 years of experience, Associates and 7 years of experience
At least 3 years of 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/Active Nursing or Physical Therapy license in state of residence.
Strong investigative skills
Strong communication and organization skills
Strong PC knowledge and skills
U.S. citizenship required

Nice To Haves

Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
Knowledge of Medicaid requirements, laws, rules and regulations related to payment for services billed
Have a CPC (Certified Professional Coder) certificate.

Responsibilities

Apply sound clinical judgment to claim payment decisions.
Conduct medical record reviews.
Conduct self-directed research to uncover problems in Medicaid payments made to institutional and non-institutional providers.
Present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government.
Research regulations and cite violations.
Use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, over payment recovery.
Work with external agencies to develop cases and corrective actions as well as respond to requests for data and support.
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, trainings, and conferences as needed.
May be required to appear in court to testify about work findings.