Job Title: Nurse Reviewer - Medicaid

Peraton Overview
Peraton drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the worlds 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 22,000 employees do the cant be done, solving the most daunting challenges facing our customers.

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.
Since 1999, SGS has preventedmore than$9.65 billion in inappropriate payments,consisting of nearly $5.98billion in proactively Prevented Dollars and more than $3.69 billion in Recovered Dollars. Our experience with fraud and abuse analytics has resulted in the referral of thousands of cases to law enforcement and resulted in successful criminal and civil prosecution and civil monetary penalties.

Position Overview:
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.


Qualifications
BS 8-10, MS 6-8, PhD 3-5

Prerequisites:
BS 8-10, MS 6-8, PhD 3-5
Three to five 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.
Telework available only from Pennsylvania, New Jersey, New York, Connecticut, Vermont, New Hampshire, Rhode Island, Maryland, DC, Massachusetts, Delaware, Maine.Current nursing license. Active license in Pennsylvania, New Jersey, New York, Connecticut, Vermont, New Hampshire, Rhode Island, Maryland, DC, Massachusetts, Delaware, Maine preferred.Strong investigative skillsStrong communication and organization skillsExperience in reviewing claims for technical requirements, performing medical review, and/or developing fraud casesStrong PC knowledge and skills
Essential Functions:
This position may require the incumbent to appear in court to testify about work findings.Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the GovernmentAbility to research regulations and cite violations.Ability to conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers.Ability to make claim payment decisions based on clinical knowledge.Ability to compose correspondence, reports and referral summary letters.Ability to communicate effectively, internally and externallyAbility 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 workAbility to attend meetings, training, and conferences, overnight travel required
For Colorado Residents
Colorado Salary Minimum: $63,190.40
Colorado Salary Maximum:$135,075.20

The estimate displayed represents the typical salary range for this position, and is just one component of Peraton's total compensation package for employees. Other rewards may include annual bonuses, short- and long-term incentives, and program-specific awards. In addition, Peraton provides a variety of benefits to employees.