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Nurse Auditor - Medicare

Jacksonville, FL 32202
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Business Group Highlights

Risk Decision

The Risk Decision group is a mission-critical provider of specialized investigative services to a broad range of organizations spanning the federal, intelligence and civilian sectors. Leveraging a nationwide footprint of highly experienced investigators and subject matter experts, we provide critical information to support sensitive decisions.


Every day at Perspecta, we enable hundreds of thousands of people to take on our nations most important work. Were a company founded on a diverse set of capabilities and skills, bound together by a single promise: we never stop solving our nations most complex challenges. Our team of engineers, analysts, developers, investigators, integrators and architects work tirelessly to create innovative solutions. We continually push ourselvesto respond, to adapt, to go further. To look ahead to the changing landscape and develop new and innovative ways to serve our customers. Perspecta works with U.S. government customers in defense, intelligence, civilian, health care, and state and local markets. Our high-caliber employees are rewarded in many waysnot only through competitive salaries and benefits packages, but the opportunity to create a meaningful impact in jobs and on projects that matter. Perspectas talented and robust workforce14,000 strongstands ready to welcome you to the team. Lets make an impact together.

SafeGuard Services (SGS), a subsidiary of Perspecta, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.
Since 1999, SGS has prevented more than $9.5 billion in inappropriate payments, consisting of over $5.9 billion in proactively Prevented Dollars and $3.6 billion in Recovered Dollars. Our experience with fraud and abuse analytics has resulted in the referral of thousands of cases to law enforcement and resulted in successful criminal and civil prosecution and civil monetary penalties.

Position Overview:
The position requires the individual to have experience conducting medical record reviews and applying sound clinical judgment to claim payment decisions or appeals. Additionally, this position requires the individual to have experience conducting quality audits of medical review staffs clinical review of prepay, post-pay, and probe reviews. The ideal individual will have experience creating training modules and presenting training materials. Responsibilities may include additional research on medical claims data and other sources of information to identify problems, review sophisticated data model output, and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. The incumbent will use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, over payment recovery. Will work with external agencies to develop cases and corrective actions as well as respond to requests for data and support.


Requires 5 to 7 years with BS/BA or 3 to 5 years with MS/MA or 0 to 2 years with PhD.

Bachelors degree in nursing. May substitute 4 years of experience for bachelors degree.

Three to five years of 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 in state of residence.
Strong investigative and analytical skills
Strong communication and organization skills
Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
Intermediate understanding of Medicare/Medicaid or healthcare auditing, strong Medicaid experience preferred
Strong familiarity with Microsoft Office tools, including intermediate to advanced knowledge of Excel

Certified Professional Coding (CPC) preferred

Essential Functions:
This position may require the incumbent to appear in court to testify about work findings.
Ability to analysis medical review staffs claim payment decisions based on clinical knowledge
Ability to analysis medical review staffs correspondence, reports and referral summary letters
Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
Ability to research regulations and cite violations.
Ability to conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers.
Ability to make claim payment decisions based on clinical knowledge
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 to deliver high quality work
Ability to attend meetings, training, and conferences, overnight travel required

About Perspecta

What matters to our nation, is what matters to us. At Perspecta, everything we do, from conducting innovative research to cultivating strong relationships, supports one imperative: ensuring that your work succeeds. Our company was formed to bring a broad array of capabilities to all parts of the public sectorfrom investigative services and IT strategy to systems work and next-generation engineering.

Our promise is simple: never stop solving our nations most complex challenges. And with a workforce of approximately 14,000, more than 48 percent of which is cleared, we have been trusted to just that, as a partner of choice across the entire sector.

Perspecta is an AA/EEO Employer - Minorities/Women/Veterans/Disabled and other protected categories.

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As a government contractor, Perspecta abides by the following provision
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)


  • Information Technology
Posted: 2020-05-25 Expires: 2020-06-24

With offerings in mission services, digital transformation and enterprise operations, our team of 14,000 engineers, analysts, investigators and architects work tirelessly to create innovative solutions. We have the expertise and experience not only to devise solutions, but to execute on them successfully.

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Nurse Auditor - Medicare

Jacksonville, FL 32202

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