医疗审核分析师 - 医疗保险
Medical Review Analyst - Medicare
职责
SafeGuard Services (SGS)，Peraton的子公司，通过数据分析、调查和医疗审查来发现、预防、阻止、减少并转介欺诈、浪费和滥用行为以进行追回。
我们正在寻找一名医疗审核员加入SGS的专业人才团队。
你将负责：
医疗审核员需要对医疗记录进行审查，并运用良好的临床判断力来做出理赔支付决定。
职责可能包括对医疗理赔数据和其他信息来源进行额外研究，以识别问题，审查复杂的模型输出，并利用各种工具检测潜在欺诈情况，支持持续的欺诈调查和信息请求。在职人员将使用各种工具识别并开发未来行政行动的案例，包括向执法部门转介、教育和超额支付追回。将与外部机构合作开发案例和纠正措施，并回应数据和支援请求。
职位和职责：
- 能够提出关注的问题，引用法规违规行为，指控欺诈政府的计划或骗局
- 研究法规并引用违规行为
- 进行自主研究，发现对机构和非机构提供者的医疗保险支付问题
- 根据临床知识做出理赔支付决定
- 该职位可能要求在职人员出庭作证，说明工作成果
- 能够撰写信函、报告和转介摘要信件
- 能够有效沟通，内部和外部皆可
- 能够处理机密材料
- 能够及时报告工作活动
- 能够独立工作并作为团队成员交付高质量的工作
- 能够参加必要的会议、培训和会议。可能需要过夜出差
- 可从美国本土地区远程办公
资格要求
基本资格：
- 本科及5年经验，硕士及3年经验，专科及7年经验
- 至少3年在医疗领域作为注册护士或其他临床医生的经验，以及/或在医疗理赔审查方面的经验，包括覆盖范围和医疗必要性
- 在居住州持有有效的护理或物理治疗执照
- 强大的调查技能
查看英文原文
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.
We are looking to add a Medical Reviewer to our SGS team of talented professionals.
What you'll do:
The Medical 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. 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.
Roles and Responsibilities:
- 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.
- 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, trainings, and conferences as needed. Overnight travel may be required.
- Telework available from contiguous United States.
Qualifications
Basic Qualifications:
- Bachelors and 5 years of experience, Masters degree and 3 years of experience, Associates and 7 years of experience
- At least 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/Active Nursing or Physical Therapy license in state of residence.
- Strong investigative skills
- Strong communication and organization skills
- Strong PC knowledge and skills
- U.S. citizenship required
Desirable Qualifications:
- Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
- Knowledge of Medicare requirements, laws, rules and regulations related to payment for services billed
- Have a CPC (Certified Professional Coder) certificate.
Peraton Overview
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.
Target Salary Range
$66,000 - $106,000. 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
EEO: Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.Originally posted on Himalayas