Remote Nurse Claims Fraud Review Specialist

Peraton; Oregon; Hybrid; USD 51,000 - 82,000; Full time

Benefits offered by this job

Medical

Dental

Vision

Life insurance

Health Savings Account

Disability insurance

Employee Assistance Program

Parental leave

401(k)

PTO

Company holidays

Job summary

Peraton is seeking a Nurse Reviewer for SafeGuard Services (SGS) to perform medical record reviews and apply clinical judgment to claim payment decisions. Telework is available from anywhere in the United States, with responsibilities including research on claims data and development of cases for potential fraud investigations.

The role requires a nursing background, current license, 5 years of BS/BA experience in the medical field, and ability to navigate Federal, State, and MCO regulations.

Qualifications

• 5 years experience with BS/BA
• 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 nursing license.
• Strong investigative skills
• Strong communication and organization skills
• Ability to apply Federal, State and Managed Care Organization (MCO) regulations to claims under review
• Strong PC knowledge and skills
• US citizenship required
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Have CPC (Certified Professional Coder) certificate.

Responsibilities

• This position may require the incumbent to appear in court to testify to 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, training, and conferences, overnight travel required.

Skills

Investigative skills

Communication skills

Organization skills

US citizenship required

Education

BS/BA degree

Job description

Peraton is seeking a Nurse Reviewer for SafeGuard Services (SGS) to perform medical record reviews and apply clinical judgment to claim payment decisions. Telework is available from anywhere in the United States, with responsibilities including research on claims data and development of cases for potential fraud investigations.

The role requires a nursing background, current license, 5 years of BS/BA experience in the medical field, and ability to navigate Federal, State, and MCO regulations.