Fraud Investigator – Administrative Actions, Medicare

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $66k - $106k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Peraton

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

🏥 Healthcare

📦 Logistics

Consulting • Healthcare • Logistics

Peraton is a mission-focused enterprise that supports national security initiatives through advanced IT and cyber services. They provide capabilities in areas such as cyber defense, cloud operations, engineering, and intelligence. With a commitment to solving complex challenges, Peraton integrates data-driven technologies to ensure mission success for their military and government clients.

📋 Description

• Serve as the point of contact for CMS regarding administrative actions related to investigations • Provide training and mentoring to team members • Maintain statistics on submitted administrative actions • Maintain template documents used to submit and process administrative actions • Review and verify evidence supporting payment suspensions, revocations, overpayments, and other administrative actions • Work with investigative teams to ensure documentation sufficiently supports administrative actions • Coordinate with CMS, law enforcement, and the Medicare Administrative Contractor throughout the action lifecycle • Monitor workload and ensure actions meet Program Integrity Manual timeframes • Prepare and submit administrative action packages to CMS and MACs for approval and processing • Speak to action development • Assist team members with workflow development • Review individual workloads during monthly meetings, assist with prioritization, and conduct staff quality control • Monitor the quality of WMM/UCM • Monitor timeliness of case updates and escalate issues to management • Monitor investigation and case progress to ensure use of available remedies, including suspension, pre-pay reviews, and revocation • Mentor team members in identifying previously undetected fraud, waste, or abuse through research, analysis, and development • Document quality-control results in WMM according to record type

🎯 Requirements

• 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 • 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 and 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 interpret laws and regulations • Ability to handle confidential material • Ability to report work activity on a timely basis • Ability to attend meetings, training, and conferences; overnight travel may be required • U.S. citizenship required • CFE or AHFI certification is desirable

🏖️ Benefits

• Telework available from Central, Eastern, Mountain, and Pacific time zones • Employees may be eligible for overtime • Employees may be eligible for shift differential • Employees may be eligible for a discretionary bonus