Fraud, Waste, and Abuse (FWA) Program Manager
$83,310–$145,793 year
On-siteNorth Carolina, United States
Job Summary
Design, implement, and manage the company's Fraud, Waste, and Abuse (FWA) program, supported by policies, processes, and technology. Lead the annual work plan for audits and monitoring, chair the Program Integrity Committee, and develop detection strategies using data mining and analytics to maximize recoveries and avoid Medicare and Medicaid claims payments. Proactively investigate FWA issues, oversee regulatory reporting to CMS and OHA, and serve as the primary contact for external oversight agencies. Prepare FWA reports for the Audit and Compliance Committee and deliver training presentations. Collaborate with business unit leaders to build a structure around payment integrity and ensure compliance with state and federal requirements.
Required Qualifications
- 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
Desired Qualifications
- Master's degree in business, management, or health care administration preferred
- Fraud examiner certification preferred
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