Medical Review Nurse – Medicaid

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $66k - $106k / year

⏰ Full Time

🟠 Senior

🔴 Lead

🦅 H1B Visa Sponsor

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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 and use tools to detect potential fraud • Support ongoing fraud investigations and requests for information • Identify and develop cases for 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 alleging schemes or scams to defraud the Government • Research regulations and cite violations • Conduct self-directed research into Medicaid payments to institutional and non-institutional providers • Make claim payment decisions based on clinical knowledge • Appear in court to testify about work findings when required • Compose correspondence, reports, and referral summary letters • Report work activity on a timely basis • Attend meetings, trainings, and conferences, including overnight travel

🎯 Requirements

• 5 years of experience with a BS/BA, 3 years with an MS/MA, 7 years with an associate degree, or 9 years with a high school degree • Experience in the medical field as a Registered Nurse or other clinician, and/or experience reviewing medical claims for coverage and medical necessity • Current nursing license • Active license in the US • 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 • Desirable: experience reviewing claims for technical requirements, performing medical review, and/or developing fraud cases • Desirable: experience with cases involving services performed for Medicaid • Desirable: CPC (Certified Professional Coder) certificate

🏖️ Benefits

• Telework available • Employees may be eligible for overtime • Employees may be eligible for shift differential • Employees may be eligible for a discretionary bonus • Equal opportunity employer, including disability and protected veterans