Complaints/Referrals Team Lead - Medicare

Peraton•,

1d•$66,000 - $106,000•Remote

About The Position

SafeGuard Services (SGS), a subsidiary of Peraton, conducts data analysis, investigations, and medical reviews to detect, prevent, deter, and reduce fraud, waste, and abuse, and to make referrals for recovery. The Complaints/Referrals Team Lead provides leadership and oversight to investigative staff, with responsibility for quality objectives, timely investigation development and resolution, and case development for referral to law enforcement or other entities. The role requires independent judgment in analyzing and reviewing complaints and referrals and determining how best to accomplish work within broadly defined policies and practices. Telework is available from Alabama, Florida, Georgia, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia.

Requirements

Eight years of experience with a BS/BA, or 12 years of experience with a high school diploma.
At least five years of relevant investigative experience.
Strong communication and organization skills.
Strong leadership background.
Strong PC knowledge and skills.
U.S. citizenship.
Ability to research and draw conclusions.
Ability to present issues of concern, cite regulatory violations, and allege schemes or scams to defraud the Government.
Ability to organize case files 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 mentor and train others.
Ability to interpret laws and regulations and handle confidential material.
Ability to report work activity on a timely basis.
Ability to work independently and as part of a team to deliver high-quality work.
Ability to attend meetings, training, and conferences; overnight travel is required.

Nice To Haves

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

Responsibilities

Serve as a point of contact for the manager.
Assist team members with referral background, analysis, and workflow development.
Review individual workloads during monthly meetings, help prioritize work, and conduct quality control for staff.
Monitor the quality of UCM/WMM.
Monitor the timeliness of case updates and prioritize referrals and complaints as leads and investigations as necessary.
Monitor complaints and referrals to ensure all available remedies are used, transfer cases to field investigations when appropriate, and recommend further review.
Mentor team members in identifying previously undetected fraud, waste, or abuse through proactive or reactive research, analysis, and development.
Document quality-control results in WMM according to record type.