Administrative Action Specialist – Team Lead

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

📋 Description

• Attain quality goals and manage workload to ensure the prompt development and resolution of various administrative actions within an investigation.

• Provide mentorship and guidance to the administrative action team.

• Advise investigation teams regarding the requirements for pursuing administrative actions.

• Serve as a primary point of contact for the manager.

• Collaborate with CMS on advancing and finalizing administrative actions.

• Support team members with workflow and the development of administrative actions.

• Evaluate workloads during meetings, assist with prioritization, and perform quality control for staff.

• Oversee the quality of WMM/UCM.

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

• Monitor the progress of administrative actions to ensure adherence to timeframes and metrics.

• Engage in investigation-requested meetings to discuss administrative actions.

• Participate in CMS high-priority projects and provide guidance to the team.

• Create efficient workflow processes and assess their effectiveness.

• Investigate issues and draw informed conclusions.

• Present concerns, regulatory violations, and allegations of fraud schemes aimed at defrauding the Government.

• Organize case files and document investigative procedures.

• Draft correspondence and reports.

• Timely report team work activities.

• Record QC results in WMM according to the type of record.

• Coordinate coverage with other designated leads during periods of absence.

⛳️ Requirements

• A minimum of 8 years of experience with a BS/BA or 12 years of experience with a HS Diploma.

• At least 8 years of relevant investigative experience is required.

• Understanding of Medicare requirements, laws, rules, and regulations regarding payment for services billed to the Program.

• Knowledge of Medicare claims processing.

• Excellent communication and organizational abilities.

• Proficient in PC skills and knowledge.

• US citizenship is mandatory.

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

• CFE or AHFI certification is a plus.

• Capability to conduct research and draw conclusions.

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

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

• Proficiency in composing correspondence and reports.

• Effective communication skills, both internally and externally.

• Ability to interpret laws and regulations.

• Capacity to handle confidential information.

• Competence in reporting work activities promptly for the team.

• Ability to work independently and collaboratively as part of a team to deliver high-quality results.

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

• Ability to document QC results in WMM according to record type.

• Capability to coordinate with other designated leads for coverage during absences.

🏝️ Benefits

• Telework options available for East Coast employees.

• Employees may qualify for overtime, shift differential, and a discretionary bonus in addition to base salary.

• Commitment to equal opportunity employment, including individuals with disabilities and protected veterans, as well as other characteristics protected by law.