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Medical Review Analyst - Medicare

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Peraton

2mo ago

  • Job
    Full-time
    Junior, Mid & Senior Level
  • Data
    Healthcare
  • United States
    Remote

AI generated summary

  • You need 2 years with a degree or 6 without, RN experience, active nursing license, investigative skills, PC proficiency, and a CPC certificate. US citizenship required; remote work available.
  • You will conduct medical record reviews, analyze claims data, identify fraud, present regulatory violations, make payment decisions, and prepare reports while collaborating with external agencies.

Requirements

  • 2 years with BS/BA or 6 years with no degree
  • 2 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 active nursing license.
  • Strong investigative skills
  • Strong communication and organization skills
  • Strong PC knowledge and skills
  • US citizenship is required
  • This is a fully remote position and you can reside within any state of the USA.
  • Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
  • Have a CPC (Certified Professional Coder) certificate.
  • Additional years of experience as a Registered Nurse.

Responsibilities

  • The Medical Review Analyst 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.
  • 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.
  • 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

FAQs

Do we support remote work?

Yes, this is a fully remote position and you can reside within any state of the USA.

Do we support Medicare?

Yes, the Medical Review Analyst position involves conducting medical record reviews related to Medicare claims and payments.

What are the basic educational requirements for this position?

The basic requirements include either 2 years of experience with a BS/BA degree or 6 years of experience without a degree.

Is a nursing license required for this position?

Yes, a current active nursing license is required.

What kind of experience is preferred for this role?

Desirable qualifications include experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases.

What is the target salary range for this position?

The target salary range for this position is $66,000 - $106,000, based on experience and other factors.

Are there opportunities for career development?

Yes, we offer career development opportunities, including tuition assistance and financing.

Will I need to travel for this position?

Yes, the position may require attendance at meetings, training, and conferences, which may involve overnight travel.

What are the key responsibilities of the Medical Review Analyst?

Responsibilities include conducting medical record reviews, making claim payment decisions, conducting research, and developing cases for potential fraud investigations.

Are there specific qualifications for investigative skills?

Strong investigative skills are required, as the role involves detecting, preventing, and making referrals for fraud, waste, and abuse.

What kind of communication skills are necessary for this role?

Strong communication skills are essential for effectively presenting issues of concern and for composing reports and correspondence.

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Peraton

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Mission & Purpose

Do the can't be done. At Peraton, we're at the forefront of delivering the next big thing every day. We're the partner of choice to help solve some of the world's most daunting challenges, delivering bold, new solutions to keep people around the world safer and more secure. How do we do it? By thinking differently. We're not mired in the past. We look at all problems with fresh eyes. We look past the obvious to bring the best talent, tech, and ideas together to completely transform how things get done. So bring your unique ideas, your entrepreneurial spirit, and your drive to succeed and get ready to be part of something bigger. Get ready to do the can't be done.