Administrative Action Specialist – Medicare

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

📋 Description

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

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

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

• Assess and confirm evidence supporting administrative actions that involve payment suspensions, revocations, overpayments, prepayment edits, and auto-denial edits.

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

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

• Track workload to guarantee that actions are completed within the timelines specified in the Program Integrity Manual.

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

• Engage in action development discussions.

• Support team members with workflow development and task prioritization.

• Oversee the quality of WMM/UCM and document QC results based on record type.

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

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

• Provide education to providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard issues.

⛳️ Requirements

• A minimum of 2 years of experience with a BS/BA or 6 years with a high school diploma/equivalent.

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

• Excellent communication and organizational skills.

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

• Strong knowledge and skills in using personal computers.

• Capability to conduct research and draw informed conclusions.

• Ability to articulate issues of concern, referencing regulatory violations and alleging schemes or scams aimed at defrauding the Government.

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

• Skilled in composing correspondence, reports, and referral summary letters.

• Competence in educating providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard matters.

• Effective communication skills with both internal and external parties.

• Capacity to interpret laws and regulations accurately.

• Ability to handle confidential information responsibly.

• Timely reporting of work activities is essential.

• Ability to work independently as well as collaboratively within a team to produce high-quality work.

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

• US citizenship is required.

• CFE or AHFI certification is preferred.

• Experience in Medicare claims processing is desirable.

🏝️ Benefits

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

• Potential eligibility for overtime pay.

• Possible shift differential for qualifying employees.

• Eligibility for a discretionary bonus may be available.