Bilingual Nurse Reviewer - Fraud & Claims Analyst (Remote)

Peraton; Reston (VA); On-site; USD 66,000 - 106,000; Full time

Job summary

Peraton, SafeGuard Services (SGS), is seeking a Medical Reviewer to conduct medical record reviews and render informed claim payment decisions. The role involves researching Medicaid regulations, identifying issues in payments, and supporting ongoing fraud investigations.

Travel to meetings or court appearances may be required. Excellent investigative and communication skills, a clinical background, and ability to work independently are essential.

Qualifications

• Bachelor's degree with 5+ years of experience, or Master's with 3+ years.
• Active Nursing or Physical Therapy license in state of residence.
• 3+ years of medical field experience as RN or clinician, or medical claims review.
• Strong investigative, communication and organizational skills.
• U.S. citizenship required.
• Bilingual English/Spanish required.

Responsibilities

• Conduct medical record reviews and apply clinical judgment to claim payment decisions.
• Research Medicaid regulations and cite violations.
• Identify problems in Medicaid payments and review data outputs.
• Prepare reports, referral letters, and court testimony if required.
• Telework available from contiguous United States.

Skills

Investigative skills

Communication

PC Knowledge

US citizenship

Bilingual English/Spanish

Education

Bachelor's + 5 years

Master's + 3 years

Associates + 7 years

Active Nursing/Physical Therapy license

Job description

Peraton, SafeGuard Services (SGS), is seeking a Medical Reviewer to conduct medical record reviews and render informed claim payment decisions. The role involves researching Medicaid regulations, identifying issues in payments, and supporting ongoing fraud investigations.

Travel to meetings or court appearances may be required. Excellent investigative and communication skills, a clinical background, and ability to work independently are essential.