护士评审员
Nurse Reviewer
职责
SafeGuard Services (SGS)，Peraton的子公司，通过数据分析、调查和医疗审查来检测、预防、阻止、减少并转介以追回欺诈、浪费和滥用行为。
我们正在为SGS的专业人才团队招聘一名护士审核员。
你将负责：
该职位要求个人进行医疗记录审核，并对理赔支付决策应用良好的临床判断。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，审查复杂的数据模型输出，并使用各种工具来检测潜在欺诈情况，支持持续的欺诈调查和信息请求。现任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、追回超额支付。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。
- 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中的问题
- 根据临床知识做出理赔支付决定
- 可远程办公，可在全美任何地方
资格要求
基本资格：
- 5年本科学历；3年硕士学历；0年博士学历
- 医疗领域的工作经验，作为注册护士或其他临床医生，以及/或在审核医疗理赔以确定覆盖范围和医疗必要性方面的经验
- 当前有效的护士执照
- 强大的调查技能
- 强大的沟通和组织技能
- 强大的电脑知识和技能
- 需要美国公民身份
最具竞争力的候选人将具备：
- 审核理赔的技术要求、进行医疗审核和/或开发欺诈案例的经验
- 拥有CPC（认证专业编码员）证书
主要职责：
- 该职位可能需要任职者出庭作证，说明工作成果
- 能够撰写信函、报告和转介摘要信件
- 能够有效进行内部和外部沟通
- 能够处理机密材料
- 能够及时报告工作活动
- 能力
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 Nurse Reviewer to our SGS team of talented professionals.
What you'll do:
The 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
- Telework available from anywhere in the United States
Qualifications
Basic Qualifications:
- 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD
- 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.
- Strong investigative skills
- Strong communication and organization skills
- Strong PC knowledge and skills
- US. citizenship required
The most competitive candidates will have:
- Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
- 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
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
$51,000 - $82,000. 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