Nurse Reviewer – Medicaid
Peraton
Posted: 10/21/2026
RN Registered Nurse – Corrections PRN
Denver Health
Posted: 10/21/2026React
LPN – Skilled and Restorative Care
Concord Hospital Health System
Posted: 10/21/2026LPN – Skilled and Restorative Care, Per Diem
Concord Hospital Health System
Posted: 10/21/2026LPN – Skilled and Restorative Care
Concord Hospital Health System
Posted: 10/21/2026
PRN Home Infusion Nurse
Naven Health
Posted: 10/21/2026Home Infusion Nurse
Naven Health
Posted: 10/21/2026
Registered Nurse – ACT, Assertive Community Treatment
St. Luke's University Health Network
Posted: 10/21/2026
Part Time Prior Authorizations Nurse, RN – Temporary
Central California Alliance for Health
Posted: 10/21/2026
Licensed Practical Nurse, LPN
Elara Capital
Posted: 10/21/2026Registered Nurse – ACT, Assertive Community Treatment
St. Luke's University Health Network
Posted: 10/21/2026
Virtual Nurse, RN – Med-Surg/Neuro Surgical Unit
Trinity Health
Posted: 10/21/2026Weekend Home Care Registered Nurse, RN
Trinity Health
Posted: 10/21/2026Travel Registered Nurse, RN, ICU, Critical Care
Trinity Health
Posted: 10/21/2026RN Registered Nurse – Corrections
Denver Health
Posted: 10/21/2026React
Registered Nurse, RN
Advocate Aurora Health
Posted: 10/21/2026
Registered Nurse – Acute Medical Telemetry
Sentara Health
Posted: 10/21/2026
Wound Nurse, RN
Tutera Senior Living and Health Care
Posted: 10/21/2026Wound Nurse, LPN
Tutera Senior Living and Health Care
Posted: 10/21/2026
Outpatient Registered Nurse – RN, Dialysis
Fresenius Medical Care
Posted: 10/21/2026Nurse Navigator – AntiAmyloid Therapeutic Clinic
Advocate Aurora Health
Posted: 10/21/2026Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical record reviews, clinical judgment for claim payment decisions, and knowledge of Medicaid regulations. Strong investigative and communication skills are essential for identifying fraud and collaborating with external agencies.
Highest-signal resume keywords
Medical Record ReviewClinical JudgmentInvestigative SkillsMedicaid Regulations KnowledgeClaim Payment Decisions
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 sources 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 referral to law enforcement, education, and overpayment recovery
- Work with external agencies to develop cases and corrective actions and 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 Medicaid payments to institutional and non-institutional providers
- Make claim payment decisions based on clinical knowledge
- Appear in court to testify about work findings, if required
- Compose correspondence, reports, and referral summary letters
- Communicate effectively internally and externally
- Handle confidential material
- Report work activity in a timely manner
- Work independently and as a member of a team to deliver high-quality work
- Attend meetings, trainings, and conferences as needed
Requirements
What you’ll need- Bachelor's degree and 5 years of experience, Master's degree and 3 years of experience, or Associate's degree and 7 years of experience
- 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/Active Nursing or Physical Therapy license in state of residence
- U.S. citizenship required
- Strong investigative skills
- Strong communication and organization skills
- Strong PC knowledge and skills
- 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
- CPC (Certified Professional Coder) certificate is desirable
Benefits
Comp & perks- Telework available from contiguous United States
- Overnight travel may be required
- Employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay
- Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Claims ReviewFraud DetectionTechnical Requirements ReviewMedical Necessity AssessmentData Analysis
Soft Skills
Strong Communication SkillsOrganizational SkillsTeam CollaborationIndependent Work
Tools & Technologies
Data Analysis ToolsFraud Investigation ToolsPC Knowledge
Certifications & Qualifications
Registered Nurse LicensePhysical Therapy LicenseCPC Certificate
Industry Keywords
MedicaidRegulatory ViolationsFraud CasesOverpayment RecoveryCourt Testimony