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PacificSource Health Plans logo
PacificSource Health Plans

Putting members first since 1933.

Fraud, Waste, and Abuse Program Manager

Program ManagerProgram ManagerFull TimeRemoteLeadTeam 1,001-5,000Since 1933H1B No SponsorCompany SiteLinkedIn

Location

Florida

Posted

6 days ago

Salary

$83.3K - $145.8K / year

Seniority

Lead

Bachelor Degree8 yrs expEnglish

Job Description

Fraud, Waste, and Abuse Program Manager

PacificSource Health Plans

• 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.

Job 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

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