Senior Medical Claims Reviewer (RN/NP) – Telework

Peraton; Linthicum (MD); Remote; USD 70,000 - 90,000; Full time

Job summary

Peraton's SafeGuard Services (SGS) seeks a Medical Reviewer to join a team focused on data analysis, investigation, and medical review to detect fraud, waste, and abuse. The role emphasizes medical record reviews, clinical judgment, and support for investigations with external agencies.

The ideal candidate has nursing or therapy credentials and experience reviewing medical claims for coverage and necessity, plus knowledge of Medicaid regulations.

Qualifications

• Licensed healthcare professional with nursing/therapy credentials.
• Experience in reviewing medical claims for coverage and medical necessity.
• Ability to conduct medical record reviews and apply clinical judgment.
• Knowledge of Medicaid payment regulations and fraud, waste and abuse detection.
• Clear, concise written and oral communication; ability to testify when required.

Responsibilities

• Conduct medical record reviews and apply clinical judgment for claim payments.
• Research regulations and cite violations; identify Medicaid payment issues.
• Develop cases for administrative action and potential referrals to law enforcement.
• Collaborate with external agencies to support fraud investigations and data requests.
• Travel may be required; telework available from contiguous United States.

Skills

Investigative skills

Communication skills

Organizational skills

PC knowledge

U.S. citizenship

Education

Bachelor's degree + 5 years experience

Master's degree + 3 years experience

Associate's degree + 7 years experience

Active Nursing or Physical Therapy license

CPC (Certified Professional Coder) certificate

Job description

Peraton's SafeGuard Services (SGS) seeks a Medical Reviewer to join a team focused on data analysis, investigation, and medical review to detect fraud, waste, and abuse. The role emphasizes medical record reviews, clinical judgment, and support for investigations with external agencies.

The ideal candidate has nursing or therapy credentials and experience reviewing medical claims for coverage and necessity, plus knowledge of Medicaid regulations.