Complaints/Referrals Team Lead - Medicare

Peraton; United States; Remote; USD 110,000 - 170,000; Full time

Job summary

SafeGuard Services (SGS), a Peraton subsidiary, seeks an Investigative Team Lead to oversee complaints/referrals investigations, mentor staff, and ensure timely case development for potential referrals to law enforcement. The role requires strong leadership, analytical acumen, and the ability to handle confidential material.

Telework is available from AL, FL, GA, NC, SC, TN, VA, WV. Responsibilities include directing the team, reviewing workload, and ensuring QC across referrals, with

Qualifications

• 8 years with a BS/BA or 12 years of experience with a HS Diploma.
• At least 5 years of relevant investigative experience.
• Strong communication and organization skills.

Responsibilities

• Lead and mentor investigative team members.
• Review referrals and complaints to ensure proper analysis and escalation.
• Oversee workload, QC, and timeliness of case updates.
• Monitor the quality of UCM/WMM and ensure proper documentation.
• Coordinate with field investigations and law enforcement as needed.
• Attend meetings and travel overnight as required.

Skills

Communication

Organization

Leadership

PC skills

Investigative experience

Medicare knowledge

Tools

WMM

UCM

Job description

Basic Qualifications:

• 8 years with a BS/BA or 12 years of experience with a HS Diploma
• At least 5 years of relevant investigative experience required.
• Strong communication and organization skills
• Strong leadership background
• Strong PC knowledge and skills
• U.S. citizenship required

Desirable Qualifications:

The most competitive candidates will have:

• Knowledge of Medicare requirements, laws, rules and regulations related to payment for services billed the Program
• Experience in developing leads and investigations, conducting detailed background and link analysis, reviewing claims data, performing medical review, and/or developing fraud cases

Essential Functions:

• 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 mentor and train others\li>
• Ability to interpret laws and regulations\li>
• Ability to handle confidential material\li>
• Ability to report work activity on a timely basis\li>
• 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
• Document QC results in WMM according to record type

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 a Complaints/Referrals Team Lead to our SGS team of talented professionals.

What You'll do:

As an Investigative Team Lead, this individual's primary responsibilities include achieving quality objectives, workload oversight to promote timely development and resolution of investigations and development of cases for referral to law enforcement or other entities and provide mentoring and guidance to investigative team. The individual exercises significant independent judgment within broadly defined policies and practices to determine the best method for accomplishing work and achieving objectives, specifically in the analysis and review of referrals and complaints that are received.

• Act as a point of contact for manager
• Assist team members with referral background, analysis, and workflow development
• Review individual workload during monthly meetings; assist with prioritization and conduct QC for staff
• Monitor the quality of UCM/WMM
• Monitor timeliness for case updates and prioritize referrals and complaints as leads and investigations as necessary
• Monitor the progress ofcomplaints and referrals to ensure use of all available remedies, transfer to field investigations, and make recommendations for further review
• Mentor team members so that they can identify previously undetected fraud, waste, or abuse through proactive or reactive research, analysis, and development.
• Telework available fromAL, FL, GA, NC, SC, TN, VA, WV