Nurse Reviewer – Medicaid

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $66k - $106k / 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 and use tools to detect potential fraud • Support ongoing fraud investigations and requests for information • Identify and develop cases for 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 and cite regulatory violations involving alleged government-fraud schemes • Conduct self-directed research into Medicaid payments to institutional and non-institutional providers • Compose correspondence, reports, and referral summary letters • Potentially appear in court to testify about work findings • Report work activity in a timely manner • Attend meetings, trainings, and conferences as needed • Travel overnight when required

🎯 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 reviewing 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 reviewing claims for technical requirements, performing medical review, and/or developing fraud cases preferred • Knowledge of Medicaid requirements, laws, rules, and regulations related to payment for services billed preferred • CPC (Certified Professional Coder) certificate desirable

🏖️ Benefits

• Telework available from contiguous United States • Employees may be eligible for overtime • Employees may be eligible for shift differential • Employees may be eligible for a discretionary bonus