Medical Review Manager - Medicare/Medicaid

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 Medical Review Manager to our SGS team of talented professionals

 

What you'll do:

 

This position entails providing direction and supervision to a staff of Nurses that review medical records and claims data to identify and research issues of potential fraud, waste and abuse. Primary responsibilities include oversight and assistance to the development of cases for referral to law enforcement or other entities and responding to requests for data and support for existing casework

• Monitor daily operations of the Medical Review Department utilizing data and metrics to analyze performance and timeliness of both Medicare and Medicaid workflows.  
• Establish department goals by setting specific measurable and timeliness goals to ensure all projects, tasks and CMS requests are completed within defined turnaround times. Implement tracking system to monitor employee progress against turnaround times.
• Regularly monitor and evaluate employee performance, completing performance reviews, providing ongoing feedback, identifying training needs and developmental opportunities.  
• Allocate team resources effectively to address workload needs, set priorities and proactively develop solutions to meet medical review project deadlines.  
• Oversee and implement training programs including the onboarding process, development of training materials and the tracking of progress and performance of all new hires. Develop ongoing and continuous training for existing staff to ensure staff knowledge on updated policies within the Medicare and Medicaid programs.
• Develop, administer, and control a budget ensuring compliance and allocation of resources to achieve departmental and organizational goals. 
• Administer compensation and other corporate polices
• Recruit and develop strategies for hiring qualified staff by assisting in job postings, interviewing and hiring decisions.
• Telework available from the contiguous United States

Basic Qualifications:

 

• 12 years of experience, may have supervisory or management experience.    
• Active Registered Nurse license in state of residence.
• Minimum of three years managerial experience in the general area of medical/ utilization review.
• Must demonstrate experience and knowledge with health care coding. 
• Must have proven leadership skills and knowledge of the Medicare and Medicaid Program as it pertains to requirements, laws, rules and regulations related to payment for services billed and for indications of potential fraud, waste and abuse.
• Requires excellent organizational and communications skills as well as strong PC skills.
• U.S. citizenship required

Prefrred Qualifictaions:

•  Bachelors degree & 10-12 years relevant experience or a, Masters degree & 8-10 years relevant experience 

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. The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces. Each day, our employees do the can’t be done by solving the most daunting challenges facing our customers. Visit peraton.com to learn how we’re keeping people around the world safe and secure.

$104,000 - $166,000. 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.

EEO: Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.