Program Manager, Fraud, Waste and Abuse

🔥 2 minutes ago

🇺🇸 United States – Remote

💵 $96.5k - $137.9k / year

⏰ Full Time

🟠 Senior

🔴 Lead

📋 Program Manager

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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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 Fraud, Waste & Abuse (FWA) and Program Integrity initiatives from strategy through implementation, ensuring regulatory compliance and operational excellence • Drive cross-functional collaboration to design, deploy, and optimize processes, systems, controls, and governance frameworks • Analyze claims, provider, member, and audit data to identify fraud trends, billing anomalies, financial risks, and recovery opportunities • Partner with analytics teams to develop detection strategies, business rules, dashboards, and investigative workflows • Oversee testing, quality assurance, and user acceptance activities to ensure solutions meet business and compliance requirements • Support audits and investigations through data analysis, documentation review, evidence gathering, and actionable recommendations • Identify operational risks and process improvement opportunities to strengthen program effectiveness and outcomes • Prepare executive-level reports and insights on program performance, audit findings, investigation results, and emerging risks • Provide leadership, mentorship, and subject matter expertise to analysts, auditors, investigators, and implementation teams • Serve as a trusted partner to clients, regulators, vendors, and internal stakeholders, driving accountability and continuous improvement

🎯 Requirements

• Bachelor’s degree in healthcare administration, pharmacy, nursing, business, public administration, criminal justice, information systems, analytics, or a related field; equivalent relevant experience may be considered • Eight or more years of progressively responsible experience in healthcare program management, program integrity, FWA, payment integrity, special investigations, compliance, auditing, claims operations, or a related discipline • Experience leading complex, cross-functional implementations from requirements and design through testing, deployment, and operational transition • Experience developing policies, procedures, process designs, test cases, user acceptance testing materials, audit workpapers, and executive-level reporting • Working knowledge of healthcare claims, provider billing, audit methodologies, investigative practices, evidence documentation, and overpayment identification • Knowledge of applicable federal and state healthcare program integrity requirements, including Medicare and/or Medicaid requirements • Strong analytical, critical-thinking, facilitation, project leadership, written communication, and presentation skills • Ability to manage multiple priorities, exercise sound judgment, protect confidential information, and work effectively with technical and nontechnical stakeholders • Ability to travel for field audits, client meetings, or implementation activities as business needs require • Experience supporting Medicaid, Medicare, managed care, pharmacy benefit management, or government healthcare programs • Experience with claims analytics, data visualization, audit or case-management platforms, and structured defect or requirements-management tools • Professional certification such as Certified Fraud Examiner, Accredited Health Care Fraud Investigator, Certified in Healthcare Compliance, Certified Internal Auditor, Project Management Professional, or an equivalent credential

🏖️ Benefits

• Work flexibility • Learning and career development • Technical credentials and certifications • Generous, flexible vacation policy • Educational assistance • Leadership and technical development academies • 401(k) employer match • Comprehensive health benefits • Opportunities to travel through your work (0-25%)