Medical Review Team Lead

Job not on LinkedIn

🔥 3 hours 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 sources to identify problems • Review sophisticated data model output and use tools to detect potential fraud • Support ongoing fraud investigations and requests for information • Act as a point of contact for the manager • Assist team members with workflow development • Review individual workloads during monthly meetings, assist with prioritization, and conduct quality control for staff • Monitor the quality of WMM/UCM • Monitor timeliness for case updates and escalate to management as necessary • Monitor the progress of investigations, audits, and cases • Mentor team members in identifying previously undetected fraud, waste, or abuse through research, analysis, review, and development • Present issues of concern, citing regulatory violations and alleged schemes or scams to defraud the Government • Make claim payment decisions based on clinical knowledge • Coordinate with other designated leads for coverage when the lead is out of the office

🎯 Requirements

• Minimum of 8 years with BS/BA or 12 years with a HS Diploma/equivalent • Experience in the medical review field as a fraud, waste, and abuse Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity • Current and active nursing license • Strong investigative skills • Strong communication and organization skills • Strong PC knowledge and skills • Applicant must be a U.S citizen • Experience in 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 the Program • CPC (Certified Professional Coder) certificate • Spanish Speaking and Writing • 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 to deliver high quality work • Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters • Ability to perform research and draw conclusions

🏖️ Benefits

• Telework available from anywhere in the United States • Overnight travel required for meetings, training, and conferences • Potential eligibility for overtime, shift differential, and a discretionary bonus in addition to base pay