Medical Review Team Lead - 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 Nurse Reviewer Team Lead to our SGS team of talented professionals.

 

What you'll do:

 

As a Nurse Reviewer Team Lead, this individual’s primary responsibilities include achieving quality objectives, workload oversight to promote timely development and resolution of medical reviews and work with the investigations team in development of cases for referral to law enforcement or other entities and provide mentoring and guidance to the medical review team.  The individual exercises significant independent judgment within broadly defined policies and practices to determine the best method for accomplishing work and achieving objectives. 

 

The individual must be well versed in 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.

 

• Act as a point of contact for manager
• Assist team members with workflow development
• Review individual workload during monthly meetings; assist with prioritization
• Monitor the quality of WMM/UCM
• Monitor timeliness for case updates and escalating to management as necessary
• Monitor the progress of investigations audits, and cases
• Mentor team members so that they can identify previously undetected fraud, waste, or abuse through proactive or reactive research, analysis, review, and development
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Make claim payment decisions based on clinical knowledge
• Facilitate communication between Medicaid MR management and reviewers, including subcontractors
• Prepare review packages for peer reviews
• Upload/download documentation from subcontractor secure sites as necessary
• Arrange and participate in meetings with internal and external parties to discuss cases and/or reviews
• Assign cases and update case tracker as cases are assigned and records are received
• Telework available from anywhere in the United States

Basic Qualifications:

• Minimum of 8 years with BS/BA or 12 years with a HS Diploma/equivalent
• Experience in the medical review field as a fraud, waste, and abuse Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity.
• Current and active nursing license
• 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
• Must be a U.S citizen

The most competitive candidates will have: 

• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Knowledge of Medicaid requirements, laws, rules and regulations related to payment for services billed the Program
• 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
• Coordinate with other designated leads if necessary, for coverage for periods where the lead is out of the office during work hours.
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
• Ability to perform research and draw conclusions
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government

 

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.

$80,000 - $128,000. 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.