Fraud Investigator (Administrative Actions) - Medicare

SafeGuard 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 Administrative Action Specialist to our SGS team of talented professionals.

What you'll do:

The Administrative Action Specialist is responsible for being a Point of Contact for CMS regarding all administrative actions related to investigations. Providing training and mentoring. Maintaining statistics on all submitted administrative actions.  Maintaining template documents used to submit and process administrative actions.   

• Review and verify evidence supporting an administrative action as it relates to payment suspensions, revocations, overpayments as well as other administrative actions that can be pursued.
• 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 timeframes 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 contiguous United States

Basic Qualifications:

• 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD

• 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 review, 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 and conduct QC for staff
• Monitor the quality of internal tracking systems
• 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.
• Mentor team members so that they can identify previously undetected fraud, waste or abuse through proactive or reactive research, analysis and development.
• 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
• U.S. citizenship required

Desirable Qualifications:

The most competitive candidates will have:

• CFE or AHFI certification

Peraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the world’s leading mission capability integrator and transformative enterprise IT provider, we deliver trusted, highly differentiated solutions and technologies to protect our nation and allies. Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace. The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces. Each day, our employees do the can’t be done by solving the most daunting challenges facing our customers. Visit peraton.com to learn how we’re keeping people around the world safe and secure.