Remote Nurse Claims Reviewer - Fraud & Compliance

QuickCruit, Inc.; Northern (KY); Hybrid; USD 51,000 - 82,000; Full time

Job summary

Peraton SafeGuard Services is seeking a Nurse Reviewer to perform medical record reviews and apply clinical judgment to payment decisions. The role involves researching regulations, identifying violations, and supporting fraud investigations while enabling telework from anywhere in the United States. You will work with a team to review Medicare and payer data, ensuring accuracy and compliance in all claims decisions.

Qualifications

• BS/BA required; 5+ years in medical field or 3+ years with MS/MA
• Current nursing license and US citizenship
• Experience reviewing medical claims for coverage and medical necessity
• Strong investigative, communication, and organizational skills
• Proficient PC skills; ability to work remotely

Responsibilities

• Review medical records to determine coverage decisions and medical necessity
• Apply clinical judgment to claim payment decisions
• Research regulations and cite violations in Medicare payments as applicable
• Identify fraud indicators and develop cases for corrective action with external agencies
• Coordinate data requests and respond to information requests for investigations

Skills

Nursing experience

Investigative skills

Communication

Organization

PC knowledge

Education

BS/BA in Nursing

MS/MA (optional)

Job description

Peraton SafeGuard Services is seeking a Nurse Reviewer to perform medical record reviews and apply clinical judgment to payment decisions. The role involves researching regulations, identifying violations, and supporting fraud investigations while enabling telework from anywhere in the United States. You will work with a team to review Medicare and payer data, ensuring accuracy and compliance in all claims decisions.