[Hiring] Bilingual Nurse Reviewer @Peraton

Role Description

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:

• Conducting additional research on medical claims data and other sources of information to identify problems.
• Reviewing sophisticated data model output.
• Utilizing a variety of tools to detect situations of potential fraud and to support ongoing fraud investigations and requests for information.
• Identifying and developing cases for future administrative action, including referral to law enforcement, education, and overpayment recovery.
• Working with external agencies to develop cases and corrective actions.
• Responding to requests for data and support.

Roles and Responsibilities:

• 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.
• This position may require the incumbent to appear in court to testify about work findings.
• Ability to compose correspondence, reports, and referral summary letters.
• Ability to communicate effectively, internally and externally.
• Ability to handle confidential material.
• Ability to report work activity on a timely basis.
• Ability to work independently and as a member of a team to deliver high quality work.
• Ability to attend meetings, trainings, and conferences as needed. Overnight travel may be required.
• Telework available from contiguous United States.

Qualifications

• 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.
• Bilingual with ability to speak and write English and Spanish.

Requirements

• 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.

Benefits

• Salary Range: $66,000 - $106,000.
• Salary is determined by various factors, including but not limited to, the scope and responsibilities of the position, the individual’s experience, education, knowledge, skills, and competencies, as well as geographic location and business and contract considerations.
• Depending on the position, employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay.

Company Description

Peraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the world’s leading mission capability integrator and transformative enterprise IT provider, we deliver trusted, highly differentiated solutions and technologies to protect our nation and allies.

Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace. The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces. Each day, our employees do the can’t be done by solving the most daunting challenges facing our customers.