Medical Review Nurse – Medicare

Peraton

. Conduct medical record reviews and apply sound clinical judgment to claim payment decisions .

Posted 11/3/2026full-timeRemote • United StatesMid-LevelSenior💰 $51,000 - $82,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical record reviews, clinical judgment, and fraud investigation within the healthcare sector. Proficient in regulatory compliance, effective communication, and case development for administrative actions.

Highest-signal resume keywords

Medical Record ReviewFraud InvestigationClinical JudgmentCPC CertificationStrong Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Claims ReviewClinical KnowledgeData AnalysisRegulatory ResearchReport CompositionFraud DetectionClaim Payment DecisionsTechnical Requirements ReviewOverpayment RecoveryCourt Testimony

Soft Skills

Investigative SkillsOrganizational SkillsAbility to Work IndependentlyTeam CollaborationConfidentiality Handling

Tools & Technologies

Data Analysis ToolsFraud Detection ToolsPC Knowledge

Certifications & Qualifications

Current Nursing LicenseCPC Certification

Industry Keywords

Medicare PaymentsHealthcare ComplianceMedical NecessityAdministrative ActionLaw-Enforcement Referral

About the role

Key responsibilities & impact

Conduct medical record reviews and apply sound clinical judgment to claim payment decisions
Research medical claims data and other information to identify problems
Review sophisticated data model output
Use tools to detect potential fraud and support ongoing fraud investigations and requests for information
Identify and develop cases for future administrative action, including law-enforcement referral, education, and overpayment recovery
Work with external agencies to develop cases and corrective actions
Respond to requests for data and support
Present issues of concern, citing regulatory violations and alleging schemes or scams to defraud the Government
Research regulations and cite violations
Conduct self-directed research to uncover problems in Medicare payments to institutional and non-institutional providers
Make claim payment decisions based on clinical knowledge
Compose correspondence, reports, and referral summary letters
Report work activity on a timely basis
Attend meetings, training, and conferences
Potentially appear in court to testify about work findings

Requirements

What you’ll need

5 years experience with BS/BA or 7 years with an Associates degree
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
Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases (most competitive candidates)
CPC (Certified Professional Coder) certificate (most competitive candidates)
Ability 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
Ability to attend meetings, training, and conferences
Overnight travel required

Benefits

Comp & perks

Medical insurance
Dental insurance
Vision insurance
Life insurance
Health savings account
Short-term disability
Long-term disability
Employee assistance program (EAP)
Parental leave
401(k)
Paid time off (PTO) for vacation
Company-paid holidays
Potential eligibility for overtime
Potential eligibility for shift differential
Potential eligibility for a discretionary bonus