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Fraud Nurse Reviewer - Medicaid ID -10050

Responsibilities

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

 

We are looking to add a Fraud Nurse Reviewer to our Medicaid team of talented professionals.

 

What you'll do:

 

The Fraud Nurse Reviewer requires the individual to conduct medical record reviews and to apply sound clinical judgment to claim payment decisions.  Responsibilities may include additional research on medical claims data and other sources of information to identify problems, review sophisticated data model output, and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. 

 

  • Use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, over payment recovery. 
  • Will work with external agencies to develop cases and corrective actions as well as respond to requests for data and support.  
  • Research regulations and cite violations and stay abreast of any changes.
  • Conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers.
  • Have knowledge of claim payment decisions based on clinical knowledge.
  • This position may require the incumbent to appear in court to testify about work findings.
  • Telework available from contiguous United States.

 

 

Qualifications

Basic Qualifications:

Desirable Qualifications:

 

  • Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
  • Have a CPC (Certified Professional Coder) certificate.
  • Telework from Eastern Time Zone preferred.

Peraton Overview

Peraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. 

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font-size: 10pt;\"\u003eResearch regulations and cite violations.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eConduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eMake claim payment decisions based on clinical knowledge.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eThis position may require the incumbent to appear in court to testify about work findings.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eAbility to compose correspondence, reports, and referral summary letters.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eAbility to communicate effectively, internally and externally.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eAbility to handle confidential material.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eAbility to report work activity on a timely basis.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eAbility to work independently and as a member of a team to deliver high quality work.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eAbility to attend meetings, training, and conferences, overnight travel required.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eKnowledge of Medicare/Medicaid.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eStrong investigative skills.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eStrong communication and organization skills.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eStrong PC knowledge and skills.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eUS Citizenship Required.\u003c/span\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp style=\"margin: 0px;\"\u003e\u003cstrong\u003eDesirable Qualifications:\u003c/strong\u003e\u003c/p\u003e\u003cp style=\"margin: 0px;\"\u003e \u003c/p\u003e\u003cul style=\"margin-top: 0in;\"\u003e\u003cli\u003eExperience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases\u003c/li\u003e\u003cli\u003eHave a CPC (Certified Professional Coder) certificate.\u003c/li\u003e\u003cli\u003e\u003cspan style=\"font-family: arial, helvetica, sans-serif; font-size: 10pt;\"\u003eTelework from Eastern Time Zone preferred.\u003c/span\u003e\u003c/li\u003e\u003c/ul\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003ch2 class=\"iCIMS_InfoMsg iCIMS_InfoField_Job\"\u003e\n\n\n\nPeraton Overview\n\n\n\u003c/h2\u003e\n\u003cdiv class=\"iCIMS_InfoMsg iCIMS_InfoMsg_Job\"\u003e\n\u003cdiv class=\"iCIMS_Expandable_Container\"\u003e\n\u003cdiv class=\"iCIMS_Expandable_Text\"\u003e\n\u003cp style=\"margin: 0px;\"\u003ePeraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the world’s leading mission capability integrator and transformative enterprise IT provider, we deliver trusted, highly differentiated solutions and technologies to protect our nation and allies. Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace. The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces. Each day, our employees do the can’t be done by solving the most daunting challenges facing our customers. Visit \u003ca href=\"http://peraton.com/\" rel=\"noopener\" target=\"_blank\"\u003eperaton.com\u003c/a\u003e to learn how we’re keeping people around the world safe and secure.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003ch2 class=\"iCIMS_InfoMsg iCIMS_InfoField_Job\"\u003e\n\n\n\nTarget Salary Range\n\n\n\u003c/h2\u003e\n\u003cdiv class=\"iCIMS_InfoMsg iCIMS_InfoMsg_Job\"\u003e\n\u003cdiv class=\"iCIMS_Expandable_Container\"\u003e\n\u003cdiv class=\"iCIMS_Expandable_Text\"\u003e\n$80,000 - $128,000. This represents the typical salary range for this position based on experience and other factors.\n\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\n\n\n\u003c/div\u003e","identifier":{"@type":"PropertyValue","name":"Peraton","value":1605240},"datePosted":"2025-01-09","validThrough":"2026-01-09T05:00:00Z","hiringOrganization":{"@type":"Organization","name":"Peraton","sameAs":"https://peraton.com","logo":"https://job-boardly-production.s3.amazonaws.com/2lzc6xzvduziqoqxowihmb8xi7ag"},"directApply":true,"employmentType":"FULL_TIME","baseSalary":{"@type":"MonetaryAmount","currency":"USD","value":{"@type":"QuantitativeValue","unitText":"YEAR","minValue":80000.0,"maxValue":128000.0}},"jobLocationType":"TELECOMMUTE","applicantLocationRequirements":[{"@type":"Country","name":"United States"}]}
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