Administrative Action Lead

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

We are looking to add an Investigative Team Lead to our SGS team of talented professionals.

 What You’ll do:

As an  Administrative Action Lead, this individual's primary responsibilities include achieving quality objectives, providing workload oversight to promote the timely development and resolution of Medicaid administrative actions, and mentoring and providing technical guidance to the Administrative Action team. The individual assists in ensuring the timely completion of administrative action work products, including Notices of Overpayment, Notices of Violation, and other state-specific administrative actions, while coordinating with CMS, state Medicaid agencies, and Program Integrity partners as appropriate. The individual exercises significant independent judgment within broadly defined policies and practices to determine the most effective methods for accomplishing work, achieving program objectives, and ensuring compliance with contractual, federal, and state requirements. There may be multiple Administrative Action Leads supporting different task orders or functional areas.

• Act as the primary point of contact for the DRA Investigation Manager.
• Assist team members with workflow development and preparation of administrative action documents.
• Review workload, assist with prioritization, and perform quality control of administrative action work products.
• Monitor the quality of UCM/WMM
• Monitor timeliness for case updates and escalating to management as necessary
• Monitor the progress of administrative actions to ensure appropriate remedies are pursued, including overpayment recovery and state-specific administrative actions.
• Mentor staff in analyzing investigative findings, translating them into defensible administrative actions, and ensuring documentation supports state and CMS requirements.
• Telework available from the Eastern Time Zone

Basic Qualifications:

• 8 years with BA ;10 years with AA or 12 years with High School diploma
• At least 5 years of experience in Medicaid or Medicare program integrity, investigations, audits, administrative actions, or healthcare compliance.
• Experience working directly with state Medicaid agencies, state Program Integrity units, or other governmental partners in developing, coordinating, and resolving administrative actions, overpayment recoveries, provider appeals, or enforcement activities.
• Strong communication and organization skills
• Strong PC knowledge and skills
• U.S. citizenship required
• Telework available from the Eastern Time Zone

Preferred Qualifications:

The most competitive candidates will have:

• Knowledge of Medicare requirements, laws, rules and regulations related to payment for services billed the Program
• Experience in reviewing claims, performing medical review, and/or developing fraud cases

Essential Functions:

• 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, accurately and thoroughly document all steps taken
• Ability to prepare Notices of Overpayment, Notices of Violation, administrative correspondence, reports, and supporting documentation.
• 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 communicate effectively, internally and externally
• Ability to interpret laws and regulations
• Ability to handle confidential material
• Ability to report work activity on a timely basis
• Ability to work independently and as a member of a team to deliver high quality work
• Ability to attend meetings, training, and conferences, overnight travel required
• Document QC results in WMM according to record type
• Coordinate with other designated leads if necessary, for coverage for periods where the lead is out of the office during work hours.