[Hiring] 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 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 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 and alleging schemes or scams to defraud the Government.
• Research regulations and cite violations.
• Conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers.
• Make claim payment decisions based on clinical knowledge.
• Telework available from anywhere in the United States.

Qualifications

• 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD.
• 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.
• Strong PC knowledge and skills.
• U.S. citizenship required.

Requirements

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

Benefits

• 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.