Medical Review Nurse

About the role

Peraton’s SafeGuard Services subsidiary is seeking a qualified Nurse Reviewer to join its team of professionals dedicated to detecting and preventing fraud, waste, and abuse in Medicare and Medicaid programs. The role involves thorough medical record analysis and applying clinical judgment to support claim payment decisions.

Key responsibilities

• Conduct detailed medical record reviews and make claim payment decisions based on clinical knowledge.
• Research medical claims data and other sources to identify irregularities and potential fraud.
• Review sophisticated data model outputs and utilize investigative tools to support ongoing fraud investigations.
• Develop cases for administrative action, including referrals to law enforcement, education initiatives, and over‑payment recovery.
• Collaborate with external agencies to create corrective actions and respond to data requests.
• Present findings, cite regulatory violations, and document alleged fraud schemes.

Required profile

• Current Registered Nurse license with proven clinical experience.
• Experience reviewing medical claims for coverage and medical necessity.
• Strong investigative, communication, and organizational abilities.
• Ability to apply Federal, State, and Managed Care Organization regulations to claims.
• US citizenship and ability to work remotely within the contiguous United States.

Required skills

• Medical record review
• Medical claims analysis

What we offer

• Telework flexibility across the contiguous United States.