Fraud, Waste, and Abuse Program Manager

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🔥 18 hours ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $83.3k - $145.8k / year

⏰ Full Time

🟠 Senior

🔴 Lead

📋 Program Manager

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PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

⚕️ Healthcare Insurance

💸 Finance

🧘 Wellness

Healthcare Insurance • Finance • Wellness

PacificSource Health Plans is a healthcare provider that offers a range of health insurance solutions, including plans for individuals, families, and employers. Their offerings include Medicare and Medicaid plans, dental coverage, and administrative services for small and large groups. Committed to member care, PacificSource emphasizes customer service and provides various resources for health management, including mental health support and wellness programs.

📋 Description

• Design, implement, and manage the company’s FWA Program. • Provide expertise to staff in developing processes for tracking, investigating, and managing suspected FWA complaints. • Analyze, report and monitor the FWA prevention efforts and provide recommendations to leadership. • Track and report company activities to ensure compliance with state and federal FWA requirements. • Build and maintain a structure around an FWA and payment integrity program supported by policies, processes, procedures, workflows, and technology. • Develop and maintain FWA policies and procedures and implement a comprehensive FWA program. • Chair the Program Integrity Committee and collaborate on the development of the annual work plan. • Develop and maintain an FWA log and tracking system. • Proactively and independently research FWA issues and effectively employ investigative resources/techniques. • Maximize recoveries and avoidance for Medicare and Medicaid claims payments. • Develop disclosure strategies for potential fraud activities to various agencies.

🎯 Requirements

• Minimum of 8 years related experience in fraud, waste, and abuse investigations, payment integrity processes, and data mining and analysis of health care claims. • Minimum of 4 years of experience implementing or maintaining a fraud, waste, and abuse and payment integrity program in health care. • Experience with regulatory agency reporting and interaction as it relates to fraud, waste, and abuse. • Minimum 4 years of related experience with Medicare and/or Medicaid programs required. • Bachelor's degree in business, management, health care administration or other related field or Associate’s degree and equivalent work experience required. • Fraud examiner certification preferred.

🏖️ Benefits

• Flexible telecommute policy • Medical, vision, and dental insurance • Incentive program • Paid time off and holidays • 401(k) plan • Volunteer opportunities • Tuition reimbursement and training • Life insurance • Options such as a flexible spending account