Medical Review Team Lead – Medicaid

Peraton

. Achieve quality objectives and oversee workload to promote timely development and resolution of medical reviews .

Posted 9/30/2026full-timeRemote • United StatesSenior💰 $80,000 - $128,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates extensive experience in medical review, fraud detection, and compliance with Federal and State regulations. Proficient in analyzing medical claims data and providing mentorship to ensure quality and timely case resolutions.

Highest-signal resume keywords

Medical Review ExperienceFraud Detection SkillsCurrent Nursing LicenseKnowledge of Medicaid RegulationsStrong Investigative Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Claims ReviewFraud, Waste, and Abuse AnalysisData AnalysisRegulatory ComplianceClaim Payment Decision Making

Soft Skills

Strong Communication SkillsOrganizational SkillsMentoring and GuidanceTeam CollaborationIndependent Work Ability

Tools & Technologies

Case TrackerSecure Document Upload/Download ToolsPC Knowledge

Certifications & Qualifications

Current Nursing LicenseCPC (Certified Professional Coder)

Industry Keywords

Medicaid RequirementsManaged Care Organization (MCO)Federal and State RegulationsMedical NecessityConfidential Material Handling

About the role

Key responsibilities & impact

Achieve quality objectives and oversee workload to promote timely development and resolution of medical reviews
Work with the investigations team to develop cases for referral to law enforcement or other entities
Provide mentoring and guidance to the medical review team
Research medical claims data and other information to identify problems
Review sophisticated data model output and use tools to detect potential fraud
Act as a point of contact for the manager
Assist team members with workflow development and prioritization
Review individual workloads during monthly meetings
Monitor WMM/UCM quality and timeliness of case updates, escalating to management as necessary
Monitor progress of investigations, audits, and cases
Identify previously undetected fraud, waste, or abuse through research, analysis, review, and development
Present issues of concern, citing regulatory violations and alleged schemes or scams defrauding the Government
Make claim payment decisions based on clinical knowledge
Facilitate communication between Medicaid medical review management and reviewers, including subcontractors
Prepare review packages for peer reviews
Upload and download documentation from subcontractor secure sites
Arrange and participate in internal and external meetings regarding cases and reviews
Assign cases and update the case tracker

Requirements

What you’ll need

Minimum of 8 years with BS/BA or 12 years with a high school diploma/equivalent
Experience in the medical review field as a fraud, waste, and abuse Nurse or other clinician, and/or experience reviewing 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
Experience 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 to the Program
CPC (Certified Professional Coder) certificate is competitive/preferred
Ability to appear in court to testify about work findings
Ability to compose correspondence, reports, and referral summary letters
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
Ability to perform research and draw conclusions

Benefits

Comp & perks

Overtime eligibility may apply
Shift differential may apply
Discretionary bonus may apply
Overnight travel opportunities/requirements