Medical Review Analyst - Medicare

Peraton; Oregon; Hybrid; USD 66,000 - 106,000; Full time

Benefits offered by this job

Telework option

Job summary

Peraton, a national security company, is seeking a Medical Review Analyst for SafeGuard Services. You will review medical records, apply clinical judgment to determine claim payments, and research data to identify fraud patterns. Clear communication and analytical skills are essential.

The role requires nursing/clinician background, licenses, and US citizenship. Telework is available from the contiguous United States.

Qualifications

• Clinical nursing or equivalent healthcare background with medical claims review experience.

Responsibilities

• Conduct medical record reviews and apply clinical judgment to claim payments.

Skills

Registered Nurse background

Clinical license

Investigative skills

Communication skills

PC knowledge

U.S. citizenship

Education

BS/BA

MS/MA

PhD

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 Review Analyst 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 GovernmentResearch 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 U.S.

Qualifications

Basic Qualifications

• 5 years with BS/BA;
• 3 years with MS/MA;
• 0 years with PhDExperience 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 licenseStrong investigative skillsStrong communication and organization skillsStrong PC knowledge and skillsU.S. citizenship required

Desirable Qualifications

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

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 externallyAbility 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 workAbility to attend meetings, training, and conferences, overnight travel required

Target Salary Range

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 benefits.

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