Admin Action Specialist

Peraton•,

5d•$51,000 - $82,000•Remote

About The Position

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, and reduce fraud, waste, and abuse, and to make referrals for recovery. The Admin Action Specialist serves as a point of contact for CMS on administrative actions related to investigations. The role develops and submits actions to CMS for approval and manages a high-volume workload requiring timely action and attention to multiple metrics. The specialist reviews and verifies evidence supporting administrative actions, including payment suspensions, revocations, overpayments, prepayment edits, and auto-denial edits. The role works with investigative teams to ensure documentation supports the proposed action and coordinates with CMS, law enforcement, and Medicare Administrative Contractors (MACs) throughout each action. The specialist monitors deadlines under the Program Integrity Manual, prepares and submits action packages to CMS and MACs, and explains the development of actions. Telework is available from all time zones.

Requirements

Two years of experience with a bachelor's degree, no experience with a master's degree, or six years of experience with a high school diploma or equivalent.
Knowledge of Medicare requirements, laws, rules, and regulations related to payment for services billed to the Program.
Strong communication and organization skills.
Experience reviewing claims, performing medical reviews, and/or developing fraud cases.
Strong PC knowledge and skills.
Ability to conduct research and draw conclusions.
Ability to present issues of concern, citing regulatory violations and alleging schemes or scams to defraud the Government.
Ability to organize a case file and 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.
U.S. citizenship required.

Nice To Haves

CFE or AHFI certification.
Medicare claims processing experience.

Responsibilities

Serve as a point of contact for CMS regarding administrative actions related to investigations.
Develop and submit administrative actions to CMS for approval.
Manage a high-volume workload requiring timely action and tracking of multiple metrics.
Review and verify evidence supporting payment suspensions, revocations, overpayments, prepayment edits, auto-denial edits, and other administrative actions.
Work with investigative teams to ensure gathered documentation is sufficient to support administrative actions.
Coordinate with CMS, law enforcement, and Medicare Administrative Contractors throughout the life of each action.
Monitor workload and ensure actions are taken within the timeframes established in the Program Integrity Manual.
Prepare and submit administrative action packages to CMS and MACs for approval and processing, and speak to the development of the actions.
Assist team members with workflow development and prioritization.
Monitor the quality of WMM/UCM and document QC results in WMM according to record type.
Monitor timeliness of case updates and escalate issues to management as necessary.
Monitor investigations and cases to ensure available remedies are used, including suspensions, prepayment reviews, and revocations.
Research issues, draw conclusions, organize case files, and accurately document steps taken.
Present concerns by citing regulatory violations and alleged schemes or scams to defraud the Government.
Compose correspondence, reports, and referral summary letters.
Educate providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard matters.
Report work activity on a timely basis and work independently and as part of a team.
Attend meetings, training, and conferences; overnight travel may be required.