Nurse Reviewer - Medicaid

Peraton; EUA; Teletrabalho; USD 66 000 - 106 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Medical, dental, vision

Life insurance

401(k)

Paid time off

Company paid holidays

Resumo da oferta

Peraton’s SafeGuard Services (SGS) is hiring a Medical Reviewer in the United States to conduct medical record reviews and apply clinical judgment to claim payment decisions. Telework is available from contiguous United States.

The role requires nursing credentials, strong investigative skills, and the ability to work independently or in a team to support fraud investigations in Medicare and Medicaid programs.

Qualificações

• Registered Nurse or clinician with experience in medical claims review.
• Experience reviewing Medicaid/claims for coverage and medical necessity.
• U.S. citizenship required.

Responsabilidades

• Conduct medical record reviews and apply clinical judgment to payment decisions.
• Research Medicaid regulations and identify violations affecting payments.
• Prepare referral letters and documentation for investigations and court testimony.

Conhecimentos

Nursing license

Investigative skills

Communication

Computer skills

Formação académica

Bachelor’s degree + 5 years experience

Master’s degree + 3 years experience

Associates + 7 years experience

Descrição da oferta de emprego

About Peraton

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 solve the most daunting challenges that our customers face. Visit peraton.com to learn how we're keeping people around the world safe and secure.

About Peraton

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 solve the most daunting challenges that our customers face. Visit peraton.com to learn how we're keeping people around the world safe and secure.

Program Overview

Performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse in Medicare and Medicaid programs.

About The Role

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.

Details

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. A full listing of available benefits can be viewed at https://www.careers.peraton.com/benefits.

EEO

Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.