行政行动专员
Administrative Action Specialist
职责
SafeGuard Services (SGS)，Peraton的子公司，通过数据分析、调查和医疗审查来检测、预防、阻止、减少并转介欺诈、浪费和滥用行为。
我们正在寻找一位 Admin Action Specialist 加入 SGS 的专业团队。
你将负责：
Admin Action Specialist 负责作为 CMS 在所有与调查相关的行政行动方面的联系人。开发并提交行动以获得 CMS 批准。处理高工作量，需要快速行动和多项指标。
- 审查并验证支持行政行动的证据，包括支付暂停、吊销、超额支付以及其他可采取的行政行动（支付暂停、吊销、预付款编辑、自动拒绝编辑）。
- 与调查团队合作，确保收集的文件足以支持行政行动。
- 在行动整个生命周期中与 CMS、执法部门和 Medicare 行政承包商合作。
- 监控工作量，确保所有行动在《项目完整性手册》规定的时间范围内完成。
- 准备并提交行政行动包给 CMS 和 MACs 以获得批准和处理，并说明行动开发情况。
- 可从东部时区远程办公
资格要求
基本要求：
- 5 年相关经验并拥有学士学位/本科或 9 年高中文凭/同等学历
- 熟悉与向计划支付服务费用相关的 Medicare 要求、法律、规则和法规
- 强大的沟通和组织能力
- 有审查索赔、进行医疗审查和/或开发欺诈案件的经验
- 熟练掌握 PC 知识和技能
- 协助团队成员进行流程开发
- 在每月会议中审查个人工作量；协助优先级排序
- 监控 WMM/UCM 的质量
- 监控案件更新的及时性，并在必要时向上级汇报
- 监控调查和案件进展，确保使用所有可用补救措施，例如暂停、预付款审查、吊销等
- 能够进行研究并得出结论
- 能够提出问题，引用法规违规行为，指控欺诈政府的计划或骗局
- 能够整理案件文件，准确且详尽地记录所有采取的步骤
- 能够撰写正式信函
查看英文原文
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 eastern time zone
Qualifications
Basic Qualifications:
- 5 years with BS/BA or 9 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
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
$66,000 - $106,000. 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