Medical Review Nurse – Medicare

🔥 6 minutes ago

🇺🇸 United States – Remote

💵 $51k - $82k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🚫👨‍🎓 No degree required

🦅 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 • Utilize tools to detect potential fraud and support ongoing fraud investigations and requests for information • Identify and develop cases for future administrative action, including referral to law enforcement, education, and overpayment recovery • Work with external agencies to develop cases and corrective actions and 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 made to institutional and non-institutional providers • Make claim payment decisions based on clinical knowledge • Compose correspondence, reports, and referral summary letters • Communicate effectively internally and externally • Handle confidential material • Report work activity on a timely basis • Attend meetings, training, and conferences; overnight travel required • Appear in court to testify about work findings when required

🎯 Requirements

• 2 years with BS/BA or 4 years with an Associates degree, or 6 years with a HS diploma/equivalent • 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)

🏖️ Benefits

• medical insurance • dental insurance • vision insurance • life insurance • health savings account • short/long term disability • 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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