Fraud Nurse Reviewer - Medicaid - Medical Claims Analysis and Investigation Expert

Join the Frontline in Combating Healthcare Fraud as a Medicaid Fraud Nurse Reviewer

Are you a dedicated and detail-oriented Registered Nurse with a passion for ensuring the integrity of healthcare systems? Do you possess a strong clinical background and a keen analytical mind? SafeGuard Services (SGS), a subsidiary of Peraton, is seeking a highly skilled Fraud Nurse Reviewer to join our dynamic Medicaid team. As a key member of our fraud detection and prevention efforts, you will play a critical role in protecting the integrity of Medicaid and ensuring that healthcare services are delivered efficiently and effectively.

About Peraton and SafeGuard Services

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. 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. SafeGuard Services, a Peraton subsidiary, specializes in data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse in healthcare programs, including Medicaid.

Job Summary

As a Fraud Nurse Reviewer - Medicaid, you will be responsible for conducting thorough medical record reviews, applying sound clinical judgment to claim payment decisions, and utilizing various tools to detect potential fraud and support ongoing investigations. This is a unique opportunity to leverage your clinical expertise and investigative skills to make a meaningful impact in the fight against healthcare fraud.

Key Responsibilities

• Conduct comprehensive medical record reviews to identify potential fraud, waste, and abuse in Medicaid claims, applying sound clinical judgment to claim payment decisions.
• Utilize various tools and data models to detect situations of potential fraud, waste, and abuse, and support ongoing investigations and requests for information.
• Develop cases for future administrative action, including referral to law enforcement, education, and overpayment recovery.
• Collaborate with external agencies to develop cases and corrective actions, and respond to requests for data and support.
• Research regulations and cite violations, staying up-to-date on changes and updates.
• Conduct self-directed research to uncover problems in Medicaid payments made to institutional and non-institutional providers.
• Make claim payment decisions based on clinical knowledge and expertise.
• Compose correspondence, reports, and referral summary letters, and communicate effectively with internal and external stakeholders.
• Handle confidential material with discretion and maintain accurate records.
• Work independently and as part of a team to deliver high-quality work, meeting deadlines and productivity standards.
• Participate in meetings, training, and conferences, including overnight travel as required.

Requirements and Qualifications

Basic Qualifications

• Minimum 5 years of experience with a Bachelor's degree; 3 years with a Master's degree; or 0 years with a Ph.D.
• 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 nursing license in the state of residence.
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government.
• Strong investigative skills and ability to conduct self-directed research.
• Excellent communication and organization skills, with ability to compose correspondence, reports, and referral summary letters.
• Ability to handle confidential material and maintain accurate records.
• Knowledge of Medicare/Medicaid and experience with medical claims analysis.
• US Citizenship required.

Desirable Qualifications

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

Skills and Competencies

To succeed as a Fraud Nurse Reviewer - Medicaid, you will need:

• Strong clinical knowledge and expertise in medical claims analysis.
• Excellent investigative and analytical skills, with ability to identify potential fraud and waste.
• Effective communication and organization skills, with ability to work independently and as part of a team.
• Proficiency in PC skills, including Microsoft Office and data analysis software.
• Ability to handle confidential material and maintain accurate records.
• Knowledge of Medicare/Medicaid regulations and guidelines.

Career Growth Opportunities and Learning Benefits

At Peraton and SafeGuard Services, we are committed to the growth and development of our employees. As a Fraud Nurse Reviewer - Medicaid, you will have opportunities to:

• Develop your skills and expertise in medical claims analysis and investigation.
• Collaborate with experienced professionals in the field of healthcare fraud detection and prevention.
• Participate in training and conferences to stay up-to-date on changes and updates in the field.
• Contribute to the development of new policies and procedures to enhance the integrity of Medicaid.

Work Environment and Company Culture

At Peraton and SafeGuard Services, we value our employees and strive to create a work environment that is supportive, inclusive, and rewarding. As a Fraud Nurse Reviewer - Medicaid, you can expect:

• A dynamic and fast-paced work environment with opportunities for growth and development.
• A team-oriented culture with experienced professionals who share a passion for healthcare integrity.
• Flexible work arrangements, including telework options.
• Competitive salary and benefits package, including opportunities for bonuses and professional development.

Compensation and Benefits

The target salary range for this position is $80,000 - $128,000, depending on experience and other factors. As a valued employee of Peraton and SafeGuard Services, you will also be eligible for a comprehensive benefits package, including:

• Medical, dental, and vision coverage.
• Retirement savings plan with company match.
• Paid time off and holidays.
• Opportunities for bonuses and professional development.

Conclusion

If you are a motivated and detail-oriented Registered Nurse with a passion for ensuring the integrity of healthcare systems, we encourage you to apply for this exciting opportunity as a Fraud Nurse Reviewer - Medicaid. As a key member of our team, you will play a critical role in protecting the integrity of Medicaid and ensuring that healthcare services are delivered efficiently and effectively. With a competitive salary and benefits package, opportunities for growth and development, and a dynamic work environment, this is a unique chance to make a meaningful impact in the fight against healthcare fraud.

Apply now to join our team and take the first step towards a rewarding career in healthcare integrity!

Apply Now