Manager – Prepayment Fraud, Waste, and Abuse Operations

🔥 18 hours ago

🏄 California – Remote

🏄 California – Remote

💵 $81k - $115.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

⚙️ Operations

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Lead and optimize Prepayment Fraud, Waste, and Abuse operations • Ensure quality, productivity, timeliness, compliance, and contractual performance objectives • Lead, develop, and optimize team performance through coaching, performance management, workforce planning, training, and employee development • Serve as escalation point for complex investigations, policy interpretation, and high-risk issues • Establish and maintain investigative governance, documentation standards, and case review methodologies • Monitor operational performance, quality outcomes, investigative trends, and emerging fraud, waste, and abuse risks • Identify process gaps, mitigate risk, and drive data-informed recommendations and continuous improvement initiatives • Partner with clients, medical consultants, compliance teams, legal representatives, and other stakeholders • Lead implementation of regulatory changes, business requirements, system enhancements, and operational improvements

🎯 Requirements

• 5+ years of experience in healthcare operations, program integrity, fraud, waste and abuse investigations, claims analysis, payment integrity, auditing, compliance, or a related healthcare field • 2+ years of leadership experience managing investigative, analytical, healthcare operations, or program integrity teams • Strong knowledge of healthcare regulations, billing requirements, claims processing, fraud, waste and abuse detection methodologies, and program integrity operations • Experience analyzing claims, provider billing activity, authorization records, healthcare data, and investigative findings • Proven ability to lead complex operational initiatives, manage competing priorities, solve problems, and implement process improvements • Excellent analytical, communication, stakeholder management, and relationship-building skills • Must reside within an hour of California State Capital

🏖️ Benefits

• Work flexibility • Learning and career development • Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies