Fraud Nurse Reviewer - Medicaid

Santa Barbara Cottage Hospital; United States; Remote; USD 66,000 - 106,000; Full time

Job summary

A leading company in healthcare is seeking a Fraud Nurse Reviewer to join their team. In this role, you will conduct medical record reviews, apply clinical judgment on claims, and use your investigative skills to support fraud investigations. The ideal candidate will have a nursing background along with strong communication and organizational skills. A great opportunity for professionals looking to impact healthcare fraud prevention and patient safety.

Qualifications

• Registered Nurse with experience in claims review preferred.
• Strong investigative and communication skills are essential.
• U.S. citizenship required.

Responsibilities

• Conduct medical record reviews and make claim payment decisions.
• Research regulations and cite violations.
• Collaborate with law enforcement on fraud cases.

Skills

Investigative skills

Communication skills

Organization skills

PC knowledge

Education

BS/BA or MS/MA in relevant field

Registered Nurse License

Job description

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 Fraud Nurse Reviewer to our SGS team of talented professionals.

What you'll do:

The position 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.

• 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 Medicare payments made to institutional and non-institutional 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 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
• Applicant must be a U.S. citizen

Desirable Qualifications:

• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Have a CPC (Certified Professional Coder) certificate.
• Bilingual with ability to speak and write English and Spanish (Preferred)

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

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.

Target Salary Range

$66,000 - $106,000. This represents the typical salary range for this position based on experience and other factors.

EEO

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