Medical Review Analyst - Medicare

Peraton; Chantilly (VA); À distance; USD 90 000 - 130 000; Plein temps

Résumé du poste

SafeGuard Services (SGS), a Peraton subsidiary, seeks a Medical Reviewer to perform medical record reviews and apply sound clinical judgment to decide on claim payments. You will research claims data, review outputs from data models, and use various tools to identify potential fraud and support investigations.

The role requires documenting findings, communicating with internal and external stakeholders, and possibly testifying in court.

Qualifications

• Bachelor's degree with 5 years of experience OR Master's degree with 3 years OR Associate's degree with 7 years of experience.
• Active nursing or physical therapy license in state of residence.
• Experience in medical claims review for coverage and medical necessity.
• U.S. citizenship required.
• Desirable: CPC (Certified Professional Coder) or claims review/ fraud experience.

Responsabilités

• Conduct medical record reviews and apply sound clinical judgment to claim payment decisions.
• Research medical claims data and other information to identify problems and review data outputs for fraud indicators.
• Develop cases for administrative action, including referrals to law enforcement and overpayment recovery.
• Work with external agencies to develop cases and respond to data requests.

Connaissances

Investigative skills

Communication skills

Active nursing/clinical license

Medical claims review experience

U.S. citizenship

Formation

Bachelor's degree + 5 years experience

Master's degree + 3 years experience

Associate's degree + 7 years experience

Description du poste

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 Medicare requirements, laws, rules and regulations related to payment for services billed
• Have a CPC (Certified Professional Coder) certificate.

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 Medicare 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.