[Hiring] Medical Review Team Lead @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 Team Lead to our SGS team of talented professionals.

As a Nurse Reviewer Team Lead, this individual’s primary responsibilities include:

• Achieving quality objectives
• Workload oversight to promote timely development and resolution of medical reviews
• Working with the investigations team in development of cases for referral to law enforcement or other entities
• Providing mentoring and guidance to the medical review team
• Exercising significant independent judgment within broadly defined policies and practices
• Researching medical claims data and other sources of information to identify problems
• Reviewing sophisticated data model output
• Utilizing a variety of tools to detect potential fraud
• Supporting ongoing fraud investigations and requests for information
• Acting as a point of contact for manager
• Assisting team members with workflow development
• Reviewing individual workload during monthly meetings; assisting with prioritization
• Monitoring the quality of WMM/UCM
• Monitoring timeliness for case updates and escalating to management as necessary
• Monitoring the progress of investigations, audits, and cases
• Mentoring team members to identify previously undetected fraud, waste, or abuse
• Presenting issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Making claim payment decisions based on clinical knowledge
• Facilitating communication between Medicaid MR management and reviewers, including subcontractors
• Preparing review packages for peer reviews
• Uploading/downloading documentation from subcontractor secure sites as necessary
• Arranging and participating in meetings with internal and external parties to discuss cases and/or reviews
• Assigning cases and updating case tracker as cases are assigned and records are received
• Telework available from anywhere in the United States

Qualifications

• Minimum of 8 years with BS/BA or 12 years with a HS Diploma/equivalent
• Experience in the medical review field as a fraud, waste, and abuse Nurse or other clinician
• Experience in review of medical claims for coverage and medical necessity
• Current and active 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
• Must be a U.S citizen

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 to the Program
• Having a CPC (Certified Professional Coder) certificate

Essential Functions

• 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, training, and conferences; overnight travel required
• Coordinate with other designated leads if necessary, for coverage for periods where the lead is out of the office during work hours
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
• Ability to perform research and draw conclusions
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government