Job Description

The Manager, Fraud, Waste & Abuse (FWA) provides leadership and oversight of the FWA area. The position involves the management of the FWA Program in compliance with CMS, AHCA and other regulatory state and federal guidelines.

KEY RESPONSIBILITIES:

Lead and oversee the FWA Program and work plan
Lead special investigations
Research, investigate and report fraud, waste and abuse cases
Utilize internal system, external platforms and appropriate state and federal guidelines to research potential FWA
Partner with the Internal Audit and Recovery Unit to help address FWA
Develop, implement and track corrective action plans
Participate in payment integrity initiatives
Responsible for the FWA Quarterly and Annual Reports
Responsible for ensuring compliance and external reporting to CMS, AHCA, and other regulators
Review and audit high-dollar and complex claim disputes
Communicate with stakeholders and recommend process improvements leveraging analytics, automation, and AI-powered tools
Educate providers, vendors and members on how to identify and report FWA cases
Develop and mentor a high-performing, accountable team, fostering a culture of professional growth and operational excellence
Work closely with the Compliance Team
Collaborate with other departments to integrate best practices and enhance overall FWA and operational solutions
Meet performance metrics and goals established for the position
Performs additional duties and responsibilities as assigned by management

The above statement reflects the general duties considered necessary to describe the principal functions of the job identified and shall not be considered as a detailed description of all work requirement inherent to the position.

QUALIFICATIONS:

Minimum of 10 years of FWA, healthcare and/or Medicare Advantage experience; strong knowledge of Medicare Advantage, CMS and AHCA regulatory requirements
Expertise in FWA, Special Investigations, claims processing, coding and medical terminology
Outstanding investigative and research skills
Proven track record in strategic planning, operations and process improvement
Able to thrive in a complex, high-pressure environment
Bachelor’s degree in Business, Healthcare Administration, or a related field
High-degree of computer literacy and advanced Excel spreadsheets for operational data analysis and reporting

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.
No Third Party Agencies or Submissions Will Be Accepted.
Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP
Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

Job Tags

Full time, Contract work,

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