Fraud Nurse Reviewer - Medicaid

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 SGS team of talented professionals.

What you'll do:

The position 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.  The incumbent will 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.  

• Ability to present issues of concern, citing regulatory violations, 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
• Telework available from contiguous United States

Basic Qualifications:

• 2 years with BS/BA; 0 years with MS/MA; 6 years with no degree
• 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
• Applicant must be a U.S. citizen

Desirable Qualifications:

• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Have a CPC (Certified Professional Coder) certificate.
• Bilingual with ability to speak and write English and Spanish (Preferred)

Essential Functions:

• This position may require the incumbent 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 attend meetings, training, and conferences, overnight travel required