Medical Review Team Lead - Medicaid

Peraton; Chantilly (VA); Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Telework available

Job summary

SafeGuard Services (SGS), a Peraton subsidiary, seeks a Nurse Reviewer Team Lead to guide medical reviews and fraud investigations within the SGS team. You will oversee workload, mentor staff, and coordinate with investigations to develop cases for referral to law enforcement or other entities.

You will analyze medical claims data, present findings, and ensure compliance with Federal, State, and MCO regulations while maintaining confidentiality and timely reporting.

Qualifications

• Minimum of 8 years with BS/BA or 12 years with HS Diploma/equivalent.
• Experience in the medical review field as fraud, waste, and abuse nurse or clinician, and/or review of medical claims for coverage and medical necessity.

Responsibilities

• 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.
• Coordinate with other designated leads for coverage for periods when the lead is out of the office during work hours.
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters.
• Ability to perform research and draw conclusions.
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government

Education

BS/BA degree

Tools

Microsoft Office

Job description

Basic Qualifications:

• Minimum of 8 years with BS/BA or 12 years with a HS Diploma/equivalent
• Experience in the medical review field as a fraud, waste, and abuse Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity.
• Current and active 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
• Must be a U.S citizen

The most competitive candidates will have:

• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Knowledge of Medicaid requirements, laws, rules and regulations related to payment for services billed the Program
• 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 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
• Coordinate with other designated leads if necessary, for coverage for periods where the lead is out of the office during work hours.
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
• Ability to perform research and draw conclusions
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government

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 Team Lead to our SGS team of talented professionals.

What you'll do:

As a Nurse Reviewer Team Lead, this individual’s primary responsibilities include achieving quality objectives, workload oversight to promote timely development and resolution of medical reviews and work with the investigations team in development of cases for referral to law enforcement or other entities and provide mentoring and guidance to the medical review team. The individual exercises significant independent judgment within broadly defined policies and practices to determine the best method for accomplishing work and achieving objectives.

The individual must be well versed in 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.

• Act as a point of contact for manager
• Assist team members with workflow development
• Review individual workload during monthly meetings; assist with prioritization
• Monitor the quality of WMM/UCM
• Monitor timeliness for case updates and escalating to management as necessary
• Monitor the progress ofinvestigations audits, and cases
• Mentor team members so that they can identify previously undetected fraud, waste, or abuse through proactive or reactive research, analysis, review, and development
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Make claim payment decisions based on clinical knowledge
• Facilitate communication between Medicaid MR management and reviewers, including subcontractors
• Prepare review packages for peer reviews
• Upload/download documentation from subcontractor secure sites as necessary
• Arrange and participate in meetings with internal and external parties to discuss cases and/or reviews
• Assign cases and update case tracker as cases are assigned and records are received
• Telework available from anywhere in the United States