Medical Review Analyst - Medicare

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.

 

What you'll do:

 

The Medical Review Analyst - Medicare will require 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 and regulations.

 

Qualifications

Basic Qualifications:

• Bachelors degree and 2 years of experience; Masters degree and 0 years; 6 years of experience in lieu of degree
• 3 to 5 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. 
• Knowledge of Medicare rules and practices
• Strong investigative skills
• Strong communication and organization skills
• Strong PC knowledge and skills
• US Citizenship

Desirable Qualifications:

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

 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

 

Benefits:

At Peraton, our benefits are designed to help keep you at your best beyond the work you do with us daily. We’re fully committed to the growth of our employees. From fully comprehensive medical plans to tuition reimbursement, tuition assistance, and fertility treatment, we are there to support you all the way. 

 

Peraton Overview

Peraton 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 and highly differentiated national security solutions and technologies that keep people safe and secure. Peraton serves as a valued partner to essential government agencies across the intelligence, space, cyber, defense, civilian, health, and state and local markets. Every day, our employees do the can’t be done, solving the most daunting challenges facing our customers.

Target Salary Range

$66,000 - $106,000. This represents the typical salary range for this position based on experience and other factors.