Nurse Reviewer

Peraton

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

Posted 9/30/2026full-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 review, clinical judgment, and fraud investigation, with a strong ability to communicate findings and collaborate with external agencies. Proficient in analyzing medical claims data and ensuring compliance with regulations while maintaining confidentiality.

Highest-signal resume keywords

Medical Record ReviewFraud InvestigationClinical JudgmentRegistered Nurse LicenseCPC Certification

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Claims ReviewData AnalysisRegulatory ResearchReport WritingClaim Payment Decision Making

Soft Skills

Strong Communication SkillsOrganizational SkillsInvestigative SkillsTeam CollaborationIndependent Work

Tools & Technologies

Fraud Detection ToolsPC Knowledge

Certifications & Qualifications

CPC CertificationCurrent Nursing License

Industry Keywords

Medicare PaymentsMedical NecessityConfidential MaterialLaw Enforcement ReferralsOverpayment Recovery

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 referrals, 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
Appear in court to testify about work findings when required
Compose correspondence, reports, and referral summary letters
Report work activity in a timely manner
Attend meetings, training, and conferences, including overnight travel

Requirements

What you’ll need

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
Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
CPC (Certified Professional Coder) certificate is advantageous
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

Telework available from anywhere in the United States
Overtime may be available
Shift differential may be available
Discretionary bonus may be available
Equal opportunity employment, including disability and protected veterans, or other characteristics protected by law