Administrative Action Specialist

Basic Qualifications:

• 2 years with BS/BA or 6 years with a HS diploma/equivalent
• Knowledge of Medicare requirements, laws, rules and regulations related to payment for services billed to the Program
• Strong communication and organization skills
• Experience in reviewing claims, performing medical reviews, and/or developing fraud cases
• Strong PC knowledge and skills
• Assist team members with workflow development
• Review individual workload during monthly meetings; assist with prioritization
• Monitor the quality of WMM/UCM
• Monitor timeliness for case updates and escalating to management as necessary
• Monitor the progress of investigations and cases to ensure use of all available remedies, i.e., suspension, pre-pay reviews, revocation, etc.
• 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 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
• Ability to attend meetings, training, and conferences, overnight travel may be required
• Document QC results in WMM according to record type
• US. citizenship required

Desirable

Qualifications:

• CFE or AHFI certification
• Medicare claims processing experience

Safe Guard 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. Developing and submitting an action to CMS for approval. Maintaining a high-volume workload that requires quick actions and multiple metrics.

• Review and verify evidence supporting administrative action as it relates to payment suspensions, revocations, over payments as well as other administrative actions that can be pursued (payment suspension, revocation, prepayment edits, auto-denial edits).
• 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 time frames 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 eastern time zone