Nurse Reviewer – Medicaid

🕒 July 27

🇺🇸 United States – Remote

💵 $66k - $106k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 12%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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 future administrative action, including law-enforcement referrals, 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 alleged schemes or scams to defraud the Government • Research regulations and cite violations • Conduct self-directed research to uncover problems in Medicaid payments to institutional and non-institutional providers • Appear in court to testify about work findings, as required • Compose correspondence, reports, and referral summary letters • Communicate effectively internally and externally • Handle confidential material • Report work activity in a timely manner • Work independently and as a member of a team to deliver high-quality work • Attend meetings, trainings, and conferences as needed

🎯 Requirements

• Bachelor's degree and 5 years of experience, Master's degree and 3 years of experience, or Associate's degree and 7 years of experience • At least 3 years of 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/Active Nursing or Physical Therapy license in state of residence • Strong investigative skills • Strong communication and organization skills • Strong PC knowledge and skills • U.S. citizenship required • Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases (desirable) • Knowledge of Medicaid requirements, laws, rules and regulations related to payment for services billed (desirable) • CPC (Certified Professional Coder) certificate (desirable)

🏖️ Benefits

• Telework available from contiguous United States • Overnight travel may be required • Employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay