Medical Review Nurse – Medicare
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Job Description
Medical Review Nurse reviewing Medicare claims and identifying fraud, waste, and abuse for Peraton’s SafeGuard Services subsidiary. Applying clinical judgment to payment decisions and investigative case development.
Responsibilities:
- 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
- Utilize tools to detect potential fraud and support ongoing fraud investigations and requests for information
- Identify and develop cases for future administrative action, including referral to law enforcement, education, and overpayment recovery
- Work with external agencies to develop cases and corrective actions and respond to requests for data and support
- Present issues of concern, citing regulatory violations and alleging schemes or scams to defraud the Government
- Research regulations and cite violations
- Conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers
- Make claim payment decisions based on clinical knowledge
- Compose correspondence, reports, and referral summary letters
- Communicate effectively internally and externally
- Handle confidential material
- Report work activity on a timely basis
- Attend meetings, training, and conferences; overnight travel required
- Appear in court to testify about work findings when required
Requirements:
- 2 years with BS/BA or 4 years with an Associates degree, or 6 years with a HS diploma/equivalent
- 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 nursing license
- Strong investigative skills
- Strong communication and organization skills
- Strong PC knowledge and skills
- US. citizenship required
- Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases (most competitive candidates)
- CPC (Certified Professional Coder) certificate (most competitive candidates)
Benefits:
- medical insurance
- dental insurance
- vision insurance
- life insurance
- health savings account
- short/long term disability
- EAP
- parental leave
- 401(k)
- paid time off (PTO) for vacation
- company paid holidays
- overtime eligibility
- shift differential eligibility
- discretionary bonus eligibility
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