Fraud Investigator – Administrative Actions, Medicare

Peraton

Fraud Investigator supporting Medicare administrative actions for Peraton subsidiary SafeGuard Services. Reviewing evidence, coordinating with CMS and law enforcement, and monitoring case timeliness.

Posted 8/25/2026full-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 while effectively managing administrative actions and mentoring team members. Proficient in case documentation, quality control, and communication with stakeholders to ensure compliance and program integrity.

Highest-signal resume keywords

Medicare Requirements KnowledgeFraud Case DevelopmentAdministrative Action ProcessingQuality Control MonitoringStrong Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ReviewMedical ReviewResearch and AnalysisCase File OrganizationDocumentation Skills

Soft Skills

MentoringOrganization SkillsPresentation Skills

Tools & Technologies

WMMUCM

Certifications & Qualifications

CFEAHFI

Industry Keywords

Program Integrity ManualPayment SuspensionsOverpaymentsRegulatory ViolationsConfidential Material Handling

About the role

Key responsibilities & impact

Serve as the point of contact for CMS regarding administrative actions related to investigations
Provide training and mentoring to team members
Maintain statistics on submitted administrative actions
Maintain template documents used to submit and process administrative actions
Review and verify evidence supporting payment suspensions, revocations, overpayments, and other administrative actions
Work with investigative teams to ensure documentation sufficiently supports administrative actions
Coordinate with CMS, law enforcement, and the Medicare Administrative Contractor throughout the action lifecycle
Monitor workload and ensure actions meet Program Integrity Manual timeframes
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 workloads during monthly meetings, assist with prioritization, and conduct staff quality control
Monitor the quality of WMM/UCM
Monitor timeliness of case updates and escalate issues to management
Monitor investigation and case progress to ensure use of available remedies, including suspension, pre-pay reviews, and revocation
Mentor team members in identifying previously undetected fraud, waste, or abuse through research, analysis, and development
Document quality-control results in WMM according to record type

Requirements

What you’ll need

5 years with BS/BA; 3 years with MS/MA; 0 years with PhD
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 review, 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 interpret laws and regulations
Ability to handle confidential material
Ability to report work activity on a timely basis
Ability to attend meetings, training, and conferences; overnight travel may be required
U.S. citizenship required
CFE or AHFI certification is desirable

Benefits

Comp & perks

Telework available from Central, Eastern, Mountain, and Pacific time zones
Employees may be eligible for overtime
Employees may be eligible for shift differential
Employees may be eligible for a discretionary bonus