Admin Action Specialist
责任安全保护服务 (SGS),是 Peraton 的子公司，执行数据分析，调查和医疗审查以检测，预防，阻止，减少和提交用于恢复欺诈，浪费和滥用。我们希望将管理行动专家添加到我们的 SGS 团队有才华的专业人员中。你会做什么：管理行动专业人士负责成为 CMS 的所有与调查有关的行政行动的联系点。开发并向 CMS 提交一个行动进行批准。保持大量的工作量需要快速采取行动和多个指标。·审查和验证有关支付暂停，撤销，过度支付以及可能进行的其他行政行动 （支付暂缓，撤销،预付修改，自动拒绝编辑）的证明。·与调查团队合作确保收集的文件足以支持行政行动。·在整个行动期间与 CMS,执法部门和医疗保险管理承包商合作。·监督工作负担，以确保所有行动都是在程序完整性手册所规定的时间框架内采取。· 准备和向 CMS 及 MAC 提交行政行动方案，以便获得批准和处理并与行动发展沟通。· 从各时区可进行远程工作资格基本资格：· 2年 BS/BA; 0年 MS/MA; 6年 HS 文凭/等级；· 对医疗保险要求，法律，规则和有关支付费用服务的规定知识；· 有能力进行交流和组织技能；• 在审查索赔，做医学检查或开发欺诈案件方面的经验；· 有力的 PC 知识和技能；监督有关案件的更新及管理情况，如有必要；监测调查和案例进展以确保使用所有可用的补救措施 （即暂停，预付审查，撤销等）·进行研究并得出结论的能力；提出关切的问题，指控违法规，涉嫌欺诈或骗局行为，以便欺诈政府的能力；组织案件档案，准确地记录所采取的所有步骤。
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Responsibilities
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 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, overpayments 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 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 all time zone
Qualifications
Basic Qualifications:
- 2 years with BS/BA; 0 years with MS/MA; 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
Desired Skills:
- CFE or AHFI certification
- Medicare claims processing experience
Peraton Overview
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.
Target Salary Range
$51,000 - $82,000. This represents the typical salary range for this position. Salary is determined by various factors, including but not limited to, the scope and responsibilities of the position, the individual’s experience, education, knowledge, skills, and competencies, as well as geographic location and business and contract considerations. Depending on the position, employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay.EEO
EEO: Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.Originally posted on Himalayas