Medical Review Analyst

Peraton; United States; Remote; USD 65,000 - 90,000; Full time

Job summary

SafeGuard Services (SGS), a Peraton subsidiary, seeks a Nurse Reviewer to join a team of professionals. The role involves medical record reviews, applying clinical judgment to claim payments, and developing fraud investigations. Telework is available from anywhere in the United States.

The position emphasizes adherence to federal and state regulations, strong communication, and independent work within a collaborative team. Qualified nurses with experience in claims review are encouraged to apply.

Qualifications

• 5 years of experience with BS/BA.
• Experience in the medical field as a Registered Nurse or clinician, or in review of medical claims for coverage and medical necessity.
• Current nursing license.
• Ability to apply Federal, State and MCO regulations to reviewed claims.
• Strong PC knowledge and skills.
• US citizenship required.

Responsibilities

• Conduct medical record reviews and apply clinical judgment to claim payment decisions.
• Research medical claims data and other sources to identify problems.
• Identify and develop cases for potential fraud, waste, and abuse.
• Prepare referrals to law enforcement, education, and overpayment recovery.
• Respond to data requests and coordinate with external agencies as needed.
• May be required to testify in court regarding findings.

Skills

Investigative skills

Communication

Organization

Regulatory knowledge

Nursing license

US citizenship

Education

BS/BA

Job description

Basic Qualifications:

• 5 years experience with BS/BA
• 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
• Ability to apply Federal, State and Managed Care Organization (MCO) regulations to claims under review
• Strong PC knowledge and skills
• US. citizenship required

The most competitive candidates will have:.

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

Essential Functions:

• This position may require the incumbent to appear in court to testify to 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

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:

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, and overpayment 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 Medicaid payments made to institutional and non-institutional providers.
• Make claim payment decisions based on clinical knowledge
• Telework available from anywhere in the United States