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 Medicaid team of talented professionals.

What you'll do:

The Fraud Nurse Reviewer 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. 

• 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.  
• Research regulations and cite violations and stay abreast of any changes.
• Conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers.
• Have knowledge of claim payment decisions based on clinical knowledge.
• This position may require the incumbent to appear in court to testify about work findings.
• Telework available from contiguous United States.

Basic Qualifications:

• 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD.
• 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 state of residence. 
• 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.
• 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.
Customer Support, $42/hr, Remote, Part-Time, No Degree Remote Customer Support, $45/hr, No Experience, Part-Time Virtual Assistant, No Degree, $45/hr, Remote, Part-Time Virtual Assistant, $42/hr, Remote, Weekend, Entry Level Remote Moderator, $42/hr, Part-Time, Weekend, No Degree Remote Phone Job, $40/hr, Part-Time, No Degree Required Remote Phone Job, $40/hr, Part-Time, No Experience Required Remote Moderator, $40/hr, College Student, Weekend Job Entry Level Phone Job, $42/hr, Remote, No Degree Required Virtual Assistant, No Degree, $40/hr, Remote, Part-Time Data Entry, No Degree, $40/hr, Part-Time, Remote Job Data Entry, No Experience, $50/hr, Remote, College Student Virtual Assistant, $40/hr, Weekend, Remote, No Experience Phone Job, $40/hr, Remote, Night Shift, No Degree Virtual Assistant, $35/hr, Remote, Part-Time, Evening Job Virtual Assistant, $40/hr, Remote, Weekend, Entry Level Data Entry, No Experience, $35/hr, Remote, College Student Remote Phone Job, $45/hr, Part-Time, No Degree Required Remote Moderator, $40/hr, Part-Time, Weekend, No Degree Remote Phone Job, $45/hr, No Degree, College Student Friendly Customer Support, $35/hr, Night Job, Remote, No Experience Remote Phone Support, $40/hr, Evening, No Experience Required Live Chat Support, $50/hr, Remote, Night Shift, No Degree Data Entry, $40/hr, Remote, Night Shift, College Student Job Virtual Assistant, No Experience, $40/hr, Remote, Weekend Weekend Customer Support, $40/hr, Remote, College Student Remote Data Entry, No Experience, $40/hr, Part-Time Live Chat Support, $40/hr, Part-Time, Remote, No Degree Remote Moderator, No Degree, $50/hr, Evening, Weekend Job Virtual Assistant, $42/hr, Evening, Remote, College Student Data Entry, $40/hr, Remote, Evening, No Experience Required Remote Moderator, $42/hr, Part-Time, Weekend, No Degree Remote Data Entry, $45/hr, No Degree, Weekend, Night Job Data Entry, No Experience, $35/hr, Remote, College Student Virtual Assistant, $42/hr, Evening, Remote, College Student Customer Support, $50/hr, Night Job, Remote, No Experience Remote Moderator, $40/hr, Weekend, No Experience Required Remote Data Entry, $45/hr, Weekend Job, College Student Remote Customer Support, $40/hr, No Experience, Part-Time Remote Phone Support, $45/hr, Evening, No Experience Required Remote Phone Job, $40/hr, Part-Time, College Student Friendly Phone Support, Remote, $50/hr, No Experience, Part-Time Live Chat Support, $40/hr, Remote, Entry Level, Part-Time Remote Phone Job, $35/hr, College Student, Night Shift Virtual Assistant, $40/hr, Remote, Night Shift, No Experience Part-Time Data Entry, $45/hr, Remote, College Student Friendly Remote Moderator, No Degree, $35/hr, Evening, Weekend Job Remote Live Chat, $40/hr, College Student, No Experience Customer Support, $42/hr, Weekend Job, Remote, No Degree Data Entry, No Degree, $45/hr, Part-Time, Remote Job Virtual Assistant, $42/hr, Remote, Weekend, No Degree Remote Data Entry, $40/hr, Part-Time, College Student Job Customer Support, $35/hr, Night Job, Remote, No Experience Data Entry, No Experience, $35/hr, Remote, College Student Virtual Assistant, $40/hr, Remote, No Experience, Evening Phone Support, $40/hr, Remote, No Experience, Evening Job Remote Customer Support, $42/hr, Night Job, No Experience Customer Support, $42/hr, Remote, Part-Time, No Degree Virtual Assistant, $40/hr, Evening, Remote, College Student Virtual Assistant, $40/hr, Remote, Night Shift, No Experience Live Chat Support, $35/hr, Remote, No Experience Required Remote Moderator, $42/hr, Part-Time, Weekend, No Degree Virtual Assistant, Remote, $40/hr, Evening, No Experience Customer Support, $40/hr, Remote, Part-Time, No Degree Remote Customer Support, $45/hr, Part-Time, College Student Phone Support, Remote, $35/hr, No Experience, Part-Time Virtual Assistant, No Experience, $42/hr, Remote, Part-Time Customer Support, No Degree, $40/hr, Remote, Weekend Job Remote Data Entry, No Experience, $40/hr, Part-Time Entry-Level Remote Data Entry, $50/hr, Evening Job Remote Data Entry, $45/hr, No Degree, Night Shift Remote Phone Job, $40/hr, Part-Time, College Student Friendly Virtual Assistant, $42/hr, Evening, Remote, College Student Virtual Assistant, $40/hr, Remote, No Degree, Night Job Remote Data Entry, $40/hr, No Degree, Weekend, Night Job Remote Moderator, $40/hr, Weekend, No Degree, Part-Time
• 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.
• Knowledge of Medicare/Medicaid.
• Strong investigative skills.
• Strong communication and organization 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 a CPC (Certified Professional Coder) certificate.
• Telework from Eastern Time Zone preferred.

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. Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace.