Medical Review Team Lead – Medicaid

Job not on LinkedIn

🔥 1 hour ago

🇺🇸 United States – Remote

💵 $80k - $128k / year

⏰ Full Time

🟠 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

• Achieve quality objectives and oversee workload to promote timely development and resolution of medical reviews • Work with the investigations team to develop cases for referral to law enforcement or other entities • Provide mentoring and guidance to the medical review team • Research medical claims data and other information to identify problems • Review sophisticated data model output and use tools to detect potential fraud • Act as a point of contact for the manager • Assist team members with workflow development and prioritization • Review individual workloads during monthly meetings • Monitor WMM/UCM quality and timeliness of case updates, escalating to management as necessary • Monitor progress of investigations, audits, and cases • Identify previously undetected fraud, waste, or abuse through research, analysis, review, and development • Present issues of concern, citing regulatory violations and alleged schemes or scams defrauding the Government • Make claim payment decisions based on clinical knowledge • Facilitate communication between Medicaid medical review management and reviewers, including subcontractors • Prepare review packages for peer reviews • Upload and download documentation from subcontractor secure sites • Arrange and participate in internal and external meetings regarding cases and reviews • Assign cases and update the case tracker

🎯 Requirements

• Minimum of 8 years with BS/BA or 12 years with a high school diploma/equivalent • Experience in the medical review field as a fraud, waste, and abuse Nurse or other clinician, and/or experience reviewing medical claims for coverage and medical necessity • Current and active 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 • Must be a U.S. citizen • Experience reviewing claims for technical requirements, performing medical review, and/or developing fraud cases • Knowledge of Medicaid requirements, laws, rules, and regulations related to payment for services billed to the Program • CPC (Certified Professional Coder) certificate is competitive/preferred • Ability to appear in court to testify about work findings • Ability to compose correspondence, reports, and referral summary letters • 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 • Ability to perform research and draw conclusions

🏖️ Benefits

• Overtime eligibility may apply • Shift differential may apply • Discretionary bonus may apply • Overnight travel opportunities/requirements