Remote Nurse Claims Investigator for Fraud & Compliance

Peraton; Reston (VA); Remote; USD 51,000 - 82,000; Full time

Job summary

Peraton is seeking a Nurse Reviewer to join the SafeGuard Services (SGS) team. The role involves medical record reviews, applying clinical judgment to payment decisions, and researching claims data to uncover fraud, waste, and abuse.

Telework is available from anywhere in the United States. The candidate will review Medicare payments, develop cases for investigations, and collaborate with external agencies as needed.

Qualifications

• 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD.
• Experience in the medical field as a Registered Nurse or 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.
• US citizenship required.
• CPC certification is a plus for competitive candidates.

Responsibilities

• Conduct medical record reviews and apply clinical judgment to claim decisions.
• Research medical claims data and other sources to identify problems.
• Review data model outputs and use tools to detect fraud.
• Develop cases for administrative action and referrals to law enforcement as needed.
• Coordinate with external agencies for case development and data requests.
• Present issues with regulatory violations and potential schemes.

Skills

Investigative skills

Communication skills

Organizational skills

Attention to detail

Independent worker

Education

BS/BA in Nursing

MS/MA in Nursing/Related Field

Nursing license

CPC (Certified Professional Coder)

Job description

Peraton is seeking a Nurse Reviewer to join the SafeGuard Services (SGS) team. The role involves medical record reviews, applying clinical judgment to payment decisions, and researching claims data to uncover fraud, waste, and abuse.

Telework is available from anywhere in the United States. The candidate will review Medicare payments, develop cases for investigations, and collaborate with external agencies as needed.