Administrative Action Specialist- Medicare

Peraton; United States; Remote; USD 65,000 - 95,000; Full time

Benefits offered by this job

Telework from EST

Job summary

SafeGuard Services (SGS), a Peraton subsidiary, seeks an Admin Action Specialist to manage administrative actions tied to CMS investigations. You will develop, submit, and coordinate actions while handling a high-volume workload and tight timelines.

The role emphasizes reviewing evidence, collaborating with CMS and law enforcement, and ensuring timely action through the Program Integrity Manual guidelines. Telework from the eastern time zone is available.

Qualifications

• 2 years with BS/BA or 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 PC knowledge and skills.
• Experience in reviewing claims and medical reviews.
• Ability to educate providers, law enforcement and other stakeholders on program safeguards.
• Ability to interpret laws and regulations and handle confidential material.

Responsibilities

• Be CMS point of contact for all administrative actions related to investigations.
• Develop and submit actions to CMS for approval.
• Maintain high-volume workload with quick actions and metrics.
• Review evidence supporting administrative actions (suspensions, revocations, etc.).
• Coordinate with Investigative Teams, CMS, law enforcement, and MACs.
• Monitor timelines per Program Integrity Manual.
• Prepare and submit action packages for CMS/MAC approval.

Skills

Communication

Organizational skills

Research and analysis

Case documentation

Reviewing claims

Regulatory compliance

Independent work

Education

BS/BA with 2 years experience or HS diploma with 6 years

Tools

WMM (case management system)

Job description

Basic Qualifications:

• 2 years with BS/BA or 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

Desirable Qualifications:

• 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 eastern time zone