Medicare Medical Review Nurse - Fraud Analytics

Peraton; Herndon (VA); Remote; USD 51,000 - 82,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401(k)

PTO & Holidays

Job summary

Peraton, a national security company, is seeking a Medical Review Nurse for Medicare who conducts medical record reviews and applies clinical judgment to determine claim payments. The role supports fraud investigations and may involve research across data sources and regulatory citations.

Telework is available from anywhere in the United States. The position requires RN licensure, five years of relevant experience, and strong investigative and communication skills to handle sensitive information

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.
• Strong PC knowledge and skills.
• US citizenship required.
• CPC certificate is a plus.

Responsibilities

• Conduct medical record reviews and apply clinical judgment to claim payment decisions.
• Perform research on medical claims data to identify problems and support fraud investigations.
• Use tools to identify and develop cases for administrative action and referrals.
• Work with external agencies to develop cases and respond to requests for data.
• Telework available from anywhere in the United States.

Skills

Investigative skills

Communication skills

PC knowledge

Education

BS/BA

RN license

Job description

Peraton, a national security company, is seeking a Medical Review Nurse for Medicare who conducts medical record reviews and applies clinical judgment to determine claim payments. The role supports fraud investigations and may involve research across data sources and regulatory citations.

Telework is available from anywhere in the United States. The position requires RN licensure, five years of relevant experience, and strong investigative and communication skills to handle sensitive information