[Hiring] Fraud Investigative Subject Matter Expert @Peraton

Role Description

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 a Fraud Investigative Subject Matter Expert to our SGS team of talented professionals.

The Investigations Subject Matter Expert (SME) is a senior investigative lead responsible for:

• Leading and developing investigative professionals.
• Providing expert-level guidance and oversight in the evaluation, interpretation, and analysis of complex investigative information and evidence.
• Identifying, extrapolating, and evaluating relationships among pieces of evidence, information, and data.
• Recognizing patterns and connections that may not be readily apparent.
• Collaborating across teams in shaping investigative and analytical strategy for complex, sensitive, high-profile, or significant matters.
• Providing advanced coaching and mentorship to investigative staff.
• Establishing direction for investigative and data review processes and procedures.
• Ensuring the team conducts thorough, accurate, defensible, and effective investigations.
• Managing staff activities in solving common and complex business/technical issues within established policies.
• Providing guidance on process improvements and recommending changes in alignment with business tactics and strategy.
• Serving as an expert resource and witness in legal and administrative proceedings.
• Testifying before grand juries, courts, administrative hearings, and other formal proceedings regarding investigative activities, evidence, analyses, findings, and results.

Essential Functions:

• Work with CMS, law enforcement, and the Medicare Administrative Contractor throughout the life of the action.
• Apply federal or state laws to investigations.
• Work with health privacy information, maintain confidentiality, and understand all the laws, rules, and regulations concerning health privacy.
• Present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government.
• Educate providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard matters.
• Provide subject matter expertise on investigative strategies for highly complex investigations of medical professional service providers.
• Participate in the coordination of large-scale multi-subject fraud schemes/investigations.
• Oversee the development of cases for future action, including referral to law enforcement, education, overpayment recovery, and other administrative actions.
• Participate in the coordination of projects with OIG, FBI/DOJ.
• Work with internal resources and senior staff at external agencies to detect and deter emerging fraud schemes.
• Provide strategic direction on stopping program vulnerabilities and deterring fraudulent providers in Medicare and Medicaid.
• Coordinate major cases involving multiple internal and external resources.
• Develop quality processes and training materials.
• Telework available from anywhere in the United States.

Qualifications

• Minimum of 12 years with a Bachelor's degree or 16 years with a HS Diploma.
• Supervisory experience in the general area of program integrity investigations.
• Experience working with CMS regulations and Medicare claims data required.
• Strong knowledge of Medicare regulations, billing practices, and reimbursement methodologies.
• Experience with fraud detection tools, claims analysis, and data mining techniques.
• Understanding of coding systems (ICD-10, CPT, HCPCS).
• Excellent analytical, investigative, and problem-solving skills.
• Strong written and verbal communication abilities, including regulatory reporting.
• Ability to manage sensitive and confidential healthcare information (HIPAA compliance).
• Must be a US Citizen.
• Must be able to obtain and maintain the required agency clearance.

Company Description

Peraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the world’s leading mission capability integrator and transformative enterprise IT provider, we deliver trusted, highly differentiated solutions and technologies to protect our nation and allies.

• Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace.
• The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces.
• Each day, our employees do the can’t be done by solving the most daunting challenges facing our customers.

Target Salary Range

$86,000 - $138,000. This represents the typical salary range for this position. Salary is determined by various factors, including but not limited to, the scope and responsibilities of the position, the individual’s experience, education, knowledge, skills, and competencies, as well as geographic location and business and contract considerations.

EEO

EEO: Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.