Medical Review Team Lead - Medicaid Job Chantilly Virginia USA,Healthcare

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

Safe Guard 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 ofinvestigations 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