Administrative Action Specialist

Peraton

. Serve as a Point of Contact for CMS regarding administrative actions related to investigations .

Posted 9/30/2026full-timeRemote • United StatesMid-LevelSenior💰 $66,000 - $106,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Medicare requirements, laws, and regulations, with a strong ability to review claims and develop fraud cases. Proficient in communication and organization, capable of preparing administrative action packages and educating stakeholders on program safeguard matters.

Highest-signal resume keywords

Medicare Requirements KnowledgeClaims Review ExperienceStrong Communication SkillsCFE or AHFI CertificationAdministrative Action Development

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingFraud Case DevelopmentEvidence VerificationResearch and AnalysisDocumentation Management

Soft Skills

Organization SkillsTeam CollaborationEffective Communication

Tools & Technologies

WMMUCMPC Proficiency

Certifications & Qualifications

CFEAHFI

Industry Keywords

MedicareProgram Integrity ManualPayment SuspensionsOverpaymentsRegulatory Violations

About the role

Key responsibilities & impact

Serve as a Point of Contact for CMS regarding administrative actions related to investigations
Develop and submit administrative actions to CMS for approval
Review and verify evidence supporting payment suspensions, revocations, overpayments, prepayment edits, and auto-denial edits
Work with Investigative Teams to ensure documentation is sufficient to support administrative actions
Work with CMS, law enforcement, and the Medicare Administrative Contractor throughout the life of each action
Monitor workload to ensure actions are completed within timeframes set forth in the Program Integrity Manual
Prepare and submit administrative action packages to CMS and MACs for approval and processing
Speak to action development
Assist team members with workflow development
Review individual workload during monthly meetings and assist with prioritization
Monitor the quality of WMM/UCM
Monitor timeliness for case updates and escalate to management as necessary
Monitor investigation and case progress to ensure use of available remedies
Document QC results in WMM according to record type

Requirements

What you’ll need

5 years with BS/BA or 9 years with a HS Diploma/equivalent
Knowledge of Medicare requirements, laws, rules and regulations related to payment for services billed to the Program
Strong communication and organization skills
Experience in reviewing claims, performing medical reviews, and/or developing fraud cases
Strong PC knowledge and skills
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 and accurately and thoroughly document all steps taken
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 may be required
US. citizenship required
CFE or AHFI certification desirable
Medicare claims processing experience desirable

Benefits

Comp & perks

Telework available from eastern time zone
Employees may be eligible for overtime
Employees may be eligible for shift differential
Employees may be eligible for a discretionary bonus