Complaints/Referrals Team Lead - Medicare

Peraton•,

2d•$66,000 - $106,000•Hybrid

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. SGS is seeking a Complaints/Referrals Team Lead to oversee investigative quality and workload, promote timely investigation development and resolution, and develop cases for referral to law enforcement or other entities. The role exercises significant independent judgment within broadly defined policies and practices, particularly when analyzing and reviewing incoming referrals and complaints. The position serves as a point of contact for the manager and supports the investigative team through guidance, mentoring, workload oversight, prioritization, and quality control. Telework is available from Alabama, Florida, Georgia, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia. Overnight travel is required to attend meetings, training, and conferences.

Requirements

At least 5 years of relevant investigative experience.
8 years of experience with a BS/BA, or 12 years of experience with a high school diploma.
Strong communication and organizational skills.
Strong leadership background.
Strong PC knowledge and skills.
U.S. citizenship required.
Ability to research and draw conclusions; present concerns citing regulatory violations and alleged schemes or scams to defraud the Government; organize and thoroughly document case files; and compose correspondence, reports, and referral summary letters.
Ability to educate relevant stakeholders on program safeguard matters, communicate effectively internally and externally, interpret laws and regulations, handle confidential material, and report work activity promptly.
Ability to mentor and train others and work independently and as a team member 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 staff quality control.
Monitor the quality of UCM/WMM.
Monitor timeliness of case updates and prioritize referrals and complaints as leads and investigations as necessary.
Monitor the progress of complaints and referrals to ensure available remedies are used, transfer matters to field investigations, and recommend further review.
Mentor team members in identifying previously undetected fraud, waste, or abuse through proactive or reactive research, analysis, and development.
Document QC results in WMM according to record type.
Research issues and draw conclusions; present concerns citing regulatory violations and alleged schemes or scams to defraud the Government.
Organize case files and accurately and thoroughly document steps taken.
Compose correspondence, reports, and referral summary letters.
Educate providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard matters.
Communicate effectively internally and externally, interpret laws and regulations, handle confidential material, and report work activity promptly.
Work independently and as part of a team to deliver high-quality work; mentor and train others.
Attend meetings, training, and conferences, including overnight travel.