Administrative Action Specialist

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

📋 Description

• Act as the primary contact for CMS concerning administrative actions related to investigations.

• Create and submit administrative actions for CMS approval.

• Examine and validate evidence that supports payment suspensions, revocations, overpayments, prepayment edits, and auto-denial edits.

• Collaborate with Investigative Teams to ensure documentation adequately supports administrative actions.

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

• Oversee workload to guarantee actions are completed within the timeframes specified in the Program Integrity Manual.

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

• Contribute to action development discussions.

• Support team members in developing workflow processes.

• Review personal workload during monthly meetings and aid in task prioritization.

• Assess 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.

• Document QC results in WMM according to record type.

⛳️ Requirements

• A minimum of 5 years of experience with a BS/BA or 9 years with a high school diploma/equivalent.

• Familiarity with Medicare requirements, laws, rules, and regulations related to service payment billed to the Program.

• Excellent communication and organizational skills.

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

• Strong proficiency in PC skills.

• Ability to conduct research and draw conclusions.

• Capacity to present issues of concern, citing regulatory violations, and alleging schemes or scams aimed at defrauding the Government.

• Proficiency in organizing case files and accurately documenting all actions taken.

• Ability to draft correspondence, reports, and referral summary letters.

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

• Effective internal and external communication skills.

• Ability to interpret laws and regulations.

• Capability to handle confidential information.

• Ability to report work activities in a timely manner.

• Ability to work independently and collaboratively within a team to deliver high-quality results.

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

• U.S. citizenship is required.

• CFE or AHFI certification is preferred.

• Experience with Medicare claims processing is desirable.

🏝️ Benefits

• Telework options available from the eastern time zone.

• Employees may qualify for overtime compensation.

• Employees may be eligible for shift differentials.

• Employees may have the opportunity to receive a discretionary bonus.