Admin Action Specialist

Peraton; Linthicum (MD); Remote; USD 65,000 - 90,000; Full time

Job summary

Peraton's SafeGuard Services (SGS) unit is seeking an Admin Action Specialist to serve as the CMS point of contact for administrative actions during investigations. Develop and submit action packages for CMS approval and manage a high-volume workload with strict timelines.

You will coordinate with Investigative Teams, CMS, law enforcement, and MACs, ensuring documentation supports actions like suspensions, revocations, and prepayment edits, while travel as needed.

Qualifications

• Knowledge of Medicare requirements for payment of services billed to the Program.
• Strong communication and organizational skills.
• Experience in reviewing claims, medical reviews, and/or fraud cases.
• Strong PC knowledge and skills.
• Assist team members with workflow development.
• Review workload during monthly meetings and assist with prioritization.
• Monitor the quality of WMM/UCM.
• Monitor case updates and escalate as necessary.
• Monitor investigations and use of remedies (suspension, revocation, etc).
• Ability to perform research and draw conclusions.
• Ability to present issues with regulatory context and potential fraud schemes.
• Ability to organize case files and document steps clearly.
• Ability to compose correspondence and referrals.
• Ability to educate providers and groups on program safeguards.

Responsibilities

• The Admin Action Specialist is the CMS point of contact for administrative actions related to investigations.
• Develop and submit actions to CMS for approval.
• Maintain a high-volume workload with fast actions and multiple metrics.
• Review and verify evidence for actions related to suspensions, revocations, and overpayments.
• Collaborate with Investigative Teams to ensure documentation supports actions.
• Work with CMS, law enforcement and MACs throughout the life of the action.
• Monitor workload to meet Program Integrity Manual timeframes.
• Prepare and submit action packages to CMS and MACs for approval.
• Telework available from all time zones.

Skills

Medicare knowledge

Communication skills

Organization skills

Claims review experience

Regulatory interpretation

Documentation

Independent & team work

Meeting deadlines

Investigations support

Education

BS/BA 2+ yrs

MS/MA not required

HS diploma/equivalent 6+ yrs

Job description

Basic Qualifications:

• 2 years with BS/BA; 0 years with MS/MA; 6 years with a HS diploma/equivalent


• Knowledge of Medicare requirements, laws, rules and regulations related to payment for services billed to the Program


• Strong communication and organization skills


• Experience in reviewing claims, performing medical reviews, and/or developing fraud cases


• Strong PC knowledge and skills


• Assist team members with workflow development


• Review individual workload during monthly meetings; assist with prioritization


• Monitor the quality of WMM/UCM


• Monitor timeliness for case updates and escalating to management as necessary


• Monitor the progress of investigations and cases to ensure use of all available remedies, i.e., suspension, pre-pay reviews, revocation, etc.


• Ability to perform research and draw conclusions


• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government


• Ability to organize a case file, accurately and thoroughly document all steps taken


• Ability to compose correspondence, reports and referral summary letters


• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters


• Ability to communicate effectively, internally and externally


• Ability to interpret laws and regulations


• 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 may be required


• Document QC results in WMM according to record type


• US. citizenship required

Desired Skills:

• CFE or AHFI certification


• Medicare claims processing experience

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

We are looking to add an Admin Action Specialist to our SGS team of talented professionals.

What you'll do:

The Admin Action Specialist is responsible for being a Point of Contact for CMS regarding all administrative actions related to investigations. Developing and submitting an action to CMS for approval. Maintaining a high-volume workload that requires quick actions and multiple metrics.

• Review and verify evidence supporting administrative action as it relates to payment suspensions, revocations, overpayments as well as other administrative actions that can be pursued (payment suspension, revocation, prepayment edits, auto-denial edits).


• Work with the Investigative Teams to ensure that the documentation gathered is sufficient to support an administrative action.


• Work with CMS, law enforcement and the Medicare Administrative Contractor throughout the life of the action.


• Monitor workload to ensure all actions are taken within the required timeframes set forth in the Program Integrity Manual.


• Prepare and submit administrative action packages to CMS and the MACs for approval and processing and speak to the action development.


• Telework available from all time zone