Administrative Action Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as the primary liaison for CMS concerning all administrative activities related to investigations.

• Create and submit administrative actions to CMS for their endorsement.

• Manage a high-volume workload that necessitates prompt actions and oversight of multiple metrics.

• Assess and validate evidence that supports administrative actions linked to payment suspensions, revocations, overpayments, prepayment edits, and auto-denial edits.

• Collaborate with Investigative Teams to ensure that documentation is adequate to substantiate administrative actions.

• Coordinate with CMS, law enforcement, and the Medicare Administrative Contractor throughout the duration of each action.

• Supervise workload to guarantee actions are executed within the stipulated timeframes established in the Program Integrity Manual.

• Prepare and send administrative action packages to CMS and MACs for approval and processing.

• Contribute to the development of administrative actions.

• Support team members in workflow development.

• Evaluate individual workloads in monthly meetings and assist with prioritization.

• Oversee the quality of WMM/UCM.

• Track the timeliness of case updates and escalate issues to management as needed.

• Monitor investigation and case progress to ensure the utilization of available remedies.

• Record QC results in WMM in accordance with record type.

⛳️ Requirements

• 2 years of experience with a BS/BA or 6 years with a HS diploma/equivalent.

• Familiarity with Medicare requirements, laws, rules, and regulations concerning payment for services billed to the Program.

• Excellent communication and organizational skills.

• Experience in reviewing claims, conducting medical reviews, and/or developing fraud cases.

• Proficient PC knowledge and skills.

• Capability to conduct research and draw meaningful conclusions.

• Ability to articulate issues of concern, referencing regulatory violations and alleging schemes or scams intended to defraud the Government.

• Skill in organizing a case file and meticulously documenting all steps taken.

• Competence in drafting correspondence, reports, and referral summary letters.

• Ability to educate providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard issues.

• Proficient in effective communication, both internally and externally.

• Capacity to interpret laws and regulations.

• Ability to manage confidential information.

• Timeliness in reporting work activity.

• Competence to work independently as well as collaboratively in a team to produce high-quality results.

• Willingness to attend meetings, training, and conferences; overnight travel may be required.

• U.S. citizenship is required.

• CFE or AHFI certification is preferred.

• Experience with Medicare claims processing is advantageous.

🏝️ Benefits

• Telework options available for those located in the eastern time zone.

• Employees may qualify for overtime compensation.

• Employees may be eligible for shift differentials.

• Employees may receive discretionary bonuses.