[Hiring] Medical Review Nurse @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 Nurse Reviewer to our SGS team of talented professionals.

What you'll do:

• Conduct medical record reviews and apply sound clinical judgment to claim payment decisions.
• Perform 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 potential fraud.
• 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.
• Telework available in the contiguous United States.

Qualifications

• 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.

Requirements

• 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.

Essential Functions

• This position may require the incumbent to appear in court to testify to 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, training, and conferences; overnight travel required.

Benefits

• Target 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.

EEO

EEO: Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.