Nurse Review Lead - Medicaid Fraud & QA (Remote)

Peraton; Reston (VA); Remote; USD 80,000 - 128,000; Full time

Benefits offered by this job

Telework available nationwide

Job summary

Peraton, via SafeGuard Services, seeks a Nurse Reviewer Team Lead for Medicaid to oversee quality objectives and workloads within the medical review team. The role includes mentoring staff and guiding investigations for fraud, waste, and abuse while leveraging data and claims analysis.

The ideal candidate has a nursing license, 8+ years with a BS/BA (or 12+ with HS), strong investigative and communication skills, and the ability to apply federal/state regs. Telework is available nationwide.

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 clinician, and/or medical claims review for coverage/necessity.
• Current and active nursing license
• Strong investigative skills
• Strong communication and organization skills
• Ability to apply Federal, State and MCO regulations to claims under review
• Strong PC knowledge
• Must be a U.S citizen
• Experience in Medicaid review and fraud cases is a plus

Responsibilities

• Act as point of contact for manager
• Assist team with workflow development
• Review workload during monthly meetings and prioritize
• Monitor quality of WMM/UCM
• Monitor timeliness for case updates and escalate as needed
• Monitor investigations, audits, and cases
• Mentor team members to detect fraud and abuse
• Present issues with regulatory citations
• Make claim payment decisions based on clinical knowledge
• Coordinate communication between Medicaid MR management and reviewers
• Prepare review packages for peer reviews
• Upload/download documentation from subcontractor sites
• Arrange meetings to discuss cases and reviews
• Assign cases and update case tracker
• Telework available nationwide

Skills

Nursing license

Investigative skills

Communication

Organization

Regulatory knowledge

PC knowledge

US citizenship

Team leadership

Education

BS/BA

HS Diploma/equivalent

Job description

Peraton, via SafeGuard Services, seeks a Nurse Reviewer Team Lead for Medicaid to oversee quality objectives and workloads within the medical review team. The role includes mentoring staff and guiding investigations for fraud, waste, and abuse while leveraging data and claims analysis.

The ideal candidate has a nursing license, 8+ years with a BS/BA (or 12+ with HS), strong investigative and communication skills, and the ability to apply federal/state regs. Telework is available nationwide.