Fraud Investigator- Medicare

Peraton; Great Falls Crossing (VA); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading IT service provider is seeking an Admin Action Specialist to join their team. The role involves acting as a Point of Contact for CMS regarding administrative actions and requires knowledge of Medicare regulations. The candidate should possess strong communication and organizational skills. This position offers remote work options but requires availability during eastern time zone hours.

Qualifications

• Experience in technical review of claims and medical records.
• Ability to perform research and draw conclusions.
• Ability to handle confidential material.

Responsibilities

• Act as Point of Contact for CMS regarding administrative actions.
• Prepare and submit administrative action packages.
• Monitor workload to ensure timely actions.

Skills

Knowledge of Medicare requirements

Strong communication skills

Strong organization skills

PC knowledge and skills

Education

4 year degree with AS/AA; 2 years with BS/BA; 6 years without degree

Job description

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. Providing training and mentoring. Maintaining statistics on all submitted administrative actions. Maintaining template documents used to submit and process administrative actions.

Review and verify evidence supporting an administrative action as it relates to payment suspensions, revocations, overpayments as well as other administrative actions that can be pursued.

• 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 any location but must be available during eastern time zone hours.

Qualifications:

• 4 year with AS/AA; 2 years with BS/BA; 0 years with MS/MA; 6 years with no degree
• Knowledge of Medicare requirements, laws, rules and regulations related to payment for services billed to the Program
• Strong communication and organization skills
• Experience in a technical review of claims and medical records, and/or developing fraud cases
• Strong PC knowledge and skills
• Assist team members with workflow development
• Review individual workload during monthly meetings; prioritizing workload
• Monitor timeliness for case updates and escalating to management as necessary
• Monitor the progress of the administrative actions
• 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 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
• US citizenship required

Preferred Qualifications:

• CFE or AHFI certification
• Medicare experience

Peraton is an equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.