External Job Posting Title Nurse Reviewer – Medicaid

Peraton; Idaho; Remote; USD 66,000 - 106,000; Full time

Benefits offered by this job

Medical benefits

401(k)

PTO

Holidays

Job summary

Peraton is seeking a Medical Reviewer to join the SafeGuard Services team. The role involves conducting medical record reviews, applying clinical judgment to payment decisions, and researching Medicaid regulations to identify issues and potential fraud.

Telework is available from the contiguous United States. The ideal candidate will have a clinical background, active nursing or therapy license, strong investigative and communication skills, and the ability to work independently or as part of a

Qualifications

• Bachelor’s degree with relevant experience or professional licensure in nursing or allied health.
• Active nursing or clinical license in resident state required.
• Strong investigative, analytical, and documentation skills.
• Excellent communication and organization abilities.
• U.S. citizenship required.

Responsibilities

• Review medical records and apply clinical judgment to claim payment decisions.
• Research Medicaid payments and regulatory requirements to identify issues.
• Develop cases for potential fraud and liaise with external agencies as needed.
• Prepare correspondence, reports, and referral summaries clearly and timely.
• May be required to testify in court and travel overnight.

Education

Bachelor's degree

Master's degree

Associate degree

Job description

Peraton Overview

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. Visit peraton.com to learn how we’re keeping people around the world safe and secure.

Responsibilities

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.

What you'll do:

The Medical Reviewer requires the individual to conduct medical record reviews and to apply sound clinical judgment to claim payment decisions.

Responsibilities may include 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 situations of potential fraud and to support the ongoing fraud investigations and requests for information. The incumbent will use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, over payment recovery. Will work with external agencies to develop cases and corrective actions as well as respond 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

Basic Qualifications:

• Bachelors and 5 years of experience, Masters degree and 3 years of experience, Associates and 7 years of experience
• 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

Desirable Qualifications:

• 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.

Target Salary Range

$66,000 - $106,000. This represents the typical salary range for this position. 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.

Benefits Statement

Peraton offers eligible employees a variety of benefits including medical, dental, vision, life, health savings account, short/long term disability, EAP, parental leave, 401(k), paid time off (PTO) for vacation, and company paid holidays. A full listing of available benefits can be viewed at https://www.careers.peraton.com/benefits.

EEO

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