Medical Review Nurse – Medicare

🔥 12 hours ago

🇺🇸 United States – Remote

💵 $51k - $82k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 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 ongoing 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 alleging schemes or scams to defraud the Government • Research regulations and cite violations • Conduct self-directed research to uncover problems in Medicare payments to institutional and non-institutional providers • Make claim payment decisions based on clinical knowledge • Compose correspondence, reports, and referral summary letters • Report work activity on a timely basis • Attend meetings, training, and conferences • Potentially appear in court to testify about work findings

🎯 Requirements

• 5 years experience with BS/BA or 7 years with an Associates degree • 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 • Strong PC knowledge and skills • US. citizenship required • Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases (most competitive candidates) • CPC (Certified Professional Coder) certificate (most competitive candidates) • Ability to appear in court to testify about work findings • Ability to compose correspondence, reports, and referral summary letters • Ability to communicate effectively, internally and externally • Ability to handle confidential material • Ability to report work activity on a timely basis • Ability to work independently and as a member of a team • Ability to attend meetings, training, and conferences • Overnight travel required

🏖️ Benefits

• Medical insurance • Dental insurance • Vision insurance • Life insurance • Health savings account • Short-term disability • Long-term disability • Employee assistance program (EAP) • Parental leave • 401(k) • Paid time off (PTO) for vacation • Company-paid holidays • Potential eligibility for overtime • Potential eligibility for shift differential • Potential eligibility for a discretionary bonus

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