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 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, and overpayment 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 Medicaid payments made to institutional and non-institutional providers.
• Make claim payment decisions based on clinical knowledge
• Telework available

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, trainings, and conferences - overnight travel required

 

Qualifications

 

Basic Qualifications:

• 5 years with BS/BA; 3 years with MS/MA; 7 years with an Associates or 9 years with a HS 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. Active license in the US
• Strong investigative skills
• Strong communication and organization skills
• Ability to apply Federal, State and Managed Care Organization (MCO) regulations to claims under review
• Strong PC knowledge and skills
• Strong PC knowledge and skills
• US. citizenship required

 

Desirable Qualifications:

• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases.
• Have worked on cases involving services performed for Medicaid.
• Have a CPC (Certified Professional Coder) certificate.

 

 

Target Salary Range$66,000 - $106,000. This represents the typical salary range for this position. Salary is determined by various factors, including but not limited to, the scope and responsibilities of the position, the individual’s experience, education, knowledge, skills, and competencies, as well as geographic location and business and contract considerations. Depending on the position, employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay.