Senior Fraud, Waste and Abuse – FWA Specialist

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🔥 49 minutes ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $65.3k - $111k / year

⏰ Full Time

🟠 Senior

✨ Fraud Specialist

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PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

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

• Support the development and maintenance of the Payment Integrity and FWA program framework. • Develop, implement, and maintain program policies, workflows, procedures, and controls. • Maintain centralized tracking and reporting systems for investigations, recoveries, referrals, and regulatory activities. • Coordinate annual audit, monitoring, and work plan activities. • Serve as primary liaison with CMS, MEDIC, OHA, Medicaid Fraud Units, and other oversight agencies. • Ensure timely and accurate submission of FWA and payment integrity reporting requirements. • Monitor regulatory requirements and recommend program enhancements. • Support internal and external audits and corrective action initiatives. • Analyze program performance, recovery results, and fraud prevention outcomes. • Identify fraud schemes, payment vulnerabilities, and emerging risks. • Collaborate with analytics teams to develop prospective and retrospective monitoring strategies. • Develop recommendations to improve program effectiveness and financial recoveries. • Develop and deliver FWA training and awareness programs. • Chair or coordinate Program Integrity Committee activities. • Prepare reports and presentations for leadership, compliance committees, and the Board. • Serve as an internal subject matter expert on FWA and Payment Integrity matters.

🎯 Requirements

• Minimum of 5 years of experience in fraud, waste, and abuse (FWA), payment integrity, healthcare compliance, claims auditing, claims analysis, or related healthcare operations functions. • Experience analyzing healthcare claims data, identifying potential payment integrity risks, and supporting FWA monitoring, reporting, or compliance activities required. • Experience working with Medicare and/or Medicaid programs preferred. • Experience with data mining, analytics, regulatory reporting, or collaboration with investigative teams is highly desirable. • Bachelor’s degree in business, management, health care administration or related field required. • Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered.

🏖️ 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