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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
- Maintain a high-volume workload requiring quick actions and management of multiple metrics
- Review and verify evidence supporting administrative actions involving 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 established 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 and prioritization
- Monitor the quality of WMM/UCM and document QC results according to record type
- Monitor timeliness of case updates and escalate to management as necessary
- Monitor investigation and case progress to ensure use of available remedies
- Educate providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard matters
Requirements
What you’ll need- 2 years with BS/BA or 6 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