Medicare Action Specialist - Remote

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

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.