Fraud Nurse Reviewer - Medicaid

Davita Inc.; Herndon (VA); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare company is seeking a Fraud Nurse Reviewer to join their team. This role involves conducting medical record reviews, applying clinical judgment for claim payments, and collaborating with law enforcement on fraud cases. The ideal candidate will have a nursing background, strong investigative skills, and proficiency in health regulations. A current nursing license and relevant experience in claims review are necessary for this position, which offers telework flexibility within the contiguous United States.

Qualifications

• 2 years with BS/BA; 0 years with MS/MA; 6 years without degree.
• Experience as a Registered Nurse or clinician, or in medical claims review.
• Current nursing license required.

Responsibilities

• Conduct medical record reviews and apply clinical judgment to payment decisions.
• Develop cases for administrative action and collaborate with external agencies.
• Research regulations and cite violations related to Medicare payments.

Skills

Investigation

Communication

Organizational Skills

Proficient PC Skills

Education

BS/BA

MS/MA

CPC Certification

Job 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 Fraud Nurse Reviewer to our SGS team of talented professionals.

What you'll do:

The position requires conducting medical record reviews and applying sound clinical judgment to claim payment decisions. Responsibilities include researching medical claims data, reviewing sophisticated data model outputs, and utilizing various tools to detect potential fraud. The incumbent will develop cases for administrative action, including law enforcement referrals, education, and overpayment recovery. They will collaborate with external agencies to develop cases, implement corrective actions, and respond to data requests.

Ability to 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 identify problems in Medicare payments to providers.
• Make claim payment decisions based on clinical knowledge.
• Telework available from contiguous United States.

Qualifications:

Basic Qualifications:

• 2 years with BS/BA; 0 years with MS/MA; 6 years with no degree.
• Experience as a Registered Nurse or clinician, or in medical claims review.
• Current nursing license.
• Strong investigative, communication, and organizational skills.
• Proficient PC skills.
• U.S. citizenship required.

Desirable Qualifications:

• Experience reviewing claims for technical requirements and developing fraud cases.
• CPC certification preferred.
• Bilingual in English and Spanish preferred.

Essential Functions:

• May require court testimony.
• Ability to write reports and correspondence.
• Effective communication skills.
• Confidentiality handling.
• Timely work reporting.
• Ability to work independently and in teams.
• Attendance at meetings and travel required.

Peraton overview and salary details are included in the original description.