Nurse Reviewer - Medicaid

Peraton

Herndon (VA)

Remote

USD 66,000 - 106,000

Full time

7 days ago

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Benefits offered by this job

Medical

Dental

Vision

Life

Health savings account

Short/long term disability

EAP

Parental leave

401(k)

PTO for vacation

Company paid holidays

Job summary

Peraton is seeking a Nurse Reviewer for Medicaid to support Safeguard Services (SGS). You will review medical records, apply clinical judgment to determine payment decisions, and assist in fraud detection and recovery efforts.

Responsibilities include researching regulations, identifying Medicaid payment issues across providers, and preparing referral letters while coordinating with external agencies. Telework is available from the contiguous United States.

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

Responsibilities

The Medical Reviewer conducts medical record reviews and applies clinical judgment to claim payment decisions.
Research regulations and cite violations; identify problems in Medicaid payments to providers.
Make claim payment decisions based on clinical knowledge; appear in court if required.
Compose correspondence, reports, and referral summary letters.
Communicate effectively with internal/external stakeholders and handle confidential material.
Work independently or in a team; overnight travel may be required.
Telework available from contiguous United States.

Skills

Investigative skills

Communication skills

Organization skills

Proficiency with PC tools

U.S. citizenship

Education

Bachelor's degree + 5 years experience

Master's degree + 3 years experience

Associate's degree + 7 years experience

Active nursing or physical therapy license

Job description

Nurse Reviewer - Medicaid

Job Locations

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 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 Medicaid 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.

Qualifications

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

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.