Medical Review Nurse – Medicaid

Peraton

Medical Review Nurse evaluating Medicaid claims using clinical judgment and regulatory research. Investigating fraud, waste, and abuse for Peraton’s SafeGuard Services subsidiary.

Posted 8/12/2026full-timeRemote • 🇺🇸 United StatesSeniorLead💰 $66,000 - $106,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in medical record review, clinical judgment, and fraud investigation, with a strong ability to apply Federal, State, and Managed Care Organization regulations to claims. Proficient in composing reports and correspondence while maintaining strong communication and organizational skills.

Highest-signal resume keywords

Medical Record ReviewFraud InvestigationClinical JudgmentCurrent Nursing LicenseRegulatory Compliance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Claims ReviewData AnalysisClaim Payment DecisionsFraud Detection ToolsResearch Skills

Soft Skills

Strong Communication SkillsOrganizational SkillsInvestigative Skills

Tools & Technologies

PC Knowledge

Certifications & Qualifications

CPC (Certified Professional Coder)

Industry Keywords

MedicaidManaged Care Organization (MCO)Regulatory ViolationsOverpayment RecoveryLaw-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 and use tools to detect potential fraud
Support ongoing fraud investigations and requests for information
Identify and develop cases for 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 into Medicaid 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 on a timely basis
Attend meetings, trainings, and conferences, including overnight travel

Requirements

What you’ll need

5 years of experience with a BS/BA, 3 years with an MS/MA, 7 years with an associate degree, or 9 years with a high school degree
Experience in the medical field as a Registered Nurse or other clinician, and/or experience reviewing medical claims for coverage and medical necessity
Current nursing license
Active license in the US
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
US citizenship required
Desirable: experience reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
Desirable: experience with cases involving services performed for Medicaid
Desirable: CPC (Certified Professional Coder) certificate

Benefits

Comp & perks

Telework available
Employees may be eligible for overtime
Employees may be eligible for shift differential
Employees may be eligible for a discretionary bonus
Equal opportunity employer, including disability and protected veterans