Nurse Reviewer – Medicaid

Peraton; Linthicum (MD); Remote; USD 70,000 - 90,000; Full time

Job summary

Peraton's SafeGuard Services (SGS) seeks a Medical Reviewer to join a team focused on data analysis, investigation, and medical review to detect fraud, waste, and abuse. The role emphasizes medical record reviews, clinical judgment, and support for investigations with external agencies.

The ideal candidate has nursing or therapy credentials and experience reviewing medical claims for coverage and necessity, plus knowledge of Medicaid regulations.

Qualifications

• Licensed healthcare professional with nursing/therapy credentials.
• Experience in reviewing medical claims for coverage and medical necessity.
• Ability to conduct medical record reviews and apply clinical judgment.
• Knowledge of Medicaid payment regulations and fraud, waste and abuse detection.
• Clear, concise written and oral communication; ability to testify when required.

Responsibilities

• Conduct medical record reviews and apply clinical judgment for claim payments.
• Research regulations and cite violations; identify Medicaid payment issues.
• Develop cases for administrative action and potential referrals to law enforcement.
• Collaborate with external agencies to support fraud investigations and data requests.
• Travel may be required; telework available from contiguous United States.

Skills

Investigative skills

Communication skills

Organizational skills

PC knowledge

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

CPC (Certified Professional Coder) certificate

Job description

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.

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.