Medical Review Analyst

🔥 15 hours ago

🇺🇸 United States – Remote

💵 $51k - $82k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Peraton

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

🏥 Healthcare

📦 Logistics

Consulting • Healthcare • Logistics

Peraton is a mission-focused enterprise that supports national security initiatives through advanced IT and cyber services. They provide capabilities in areas such as cyber defense, cloud operations, engineering, and intelligence. With a commitment to solving complex challenges, Peraton integrates data-driven technologies to ensure mission success for their military and government clients.

📋 Description

• Conduct medical record reviews and apply sound clinical judgment to claim payment decisions • Research medical claims data and other information to identify problems • Review sophisticated data model output • Use tools to detect potential fraud and support fraud investigations and requests for information • Identify and develop cases for future administrative action, including law-enforcement referral, education, and overpayment recovery • Work with external agencies to develop cases and corrective actions • Respond to requests for data and support • Present issues of concern, citing regulatory violations and alleged schemes or scams to defraud the Government • Research regulations and cite violations • Conduct self-directed research to uncover problems in Medicaid payments to institutional and non-institutional providers • Make claim payment decisions based on clinical knowledge • Potentially appear in court to testify to work findings • Compose correspondence, reports, and referral summary letters • Communicate effectively internally and externally • Handle confidential material • Report work activity in a timely manner • Work independently and as part of a team • Attend meetings, training, and conferences; overnight travel required

🎯 Requirements

• 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 • U.S. citizenship required • Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases • Experience with cases involving services performed for Medicaid • CPC (Certified Professional Coder) certificate

🏖️ Benefits

• Medical, dental, and vision insurance • Life insurance • Health savings account • Short-term and long-term disability • Employee assistance program (EAP) • Parental leave • 401(k) • Paid time off (PTO) for vacation • Company-paid holidays • Overtime eligibility • Shift differential eligibility • Discretionary bonus eligibility

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