Remote Medical Claims Fraud Analyst

Embedded Shishya; United States; Remote; USD 66,000 - 106,000; Full time

Job summary

Peraton's SafeGuard Services (SGS) seeks a Medical Reviewer to conduct medical record reviews and apply clinical judgment for claim payment decisions. You will research claims data, review data outputs, and use tools to identify fraud indicators for ongoing investigations and information requests.

The role requires clinical experience, strong communication, and the ability to work independently or in a team, with potential court appearance and telework from the contiguous United States.

Qualifications

• Minimum formal education aligned with medical review and claims.
• Active nursing or clinical license in state of residence.
• Experience in medical claims review or coverage determinations.

Responsibilities

• Review medical records and apply clinical judgment to payment decisions.
• Research regulations and cite violations related to Medicare payments.
• Prepare reports and correspondence on findings for investigations.
• Appear in court to testify about work findings if required.
• Communicate results internally and with external agencies as needed.
• Telework available from contiguous United States.

Skills

Investigative skills

Communication

Organization

PC knowledge

US citizenship

Education

Bachelor's degree

Master's degree

Associate's degree

Job description

Peraton's SafeGuard Services (SGS) seeks a Medical Reviewer to conduct medical record reviews and apply clinical judgment for claim payment decisions. You will research claims data, review data outputs, and use tools to identify fraud indicators for ongoing investigations and information requests.

The role requires clinical experience, strong communication, and the ability to work independently or in a team, with potential court appearance and telework from the contiguous United States.