Fraud, Waste, and Abuse Investigations Manager

Job Summary Exemption Status: United States of America (Exempt). Pay range: $85,356 - $115,232 - $145,107. Position is not eligible for sponsorship. Responsibilities Responsible for fraud and abuse detection activities for the state defined PBA Programs, including the Fraud and Abuse Compliance Plan. Will be responsible for day‑to‑day Provider investigation-related inquiries. Utilizes prescription and medical claim data to generate clinical recommendations according to "Global" Drug Utilization Review program protocols. Provides clinical recommendations pertaining to gaps in care, high‑risk medications, compliance and adherence, drug interactions, therapeutic substitution, and generic substitution. Utilizes client formulary information to guide appropriate medication recommendations and keeps current with new and emerging clinical trends. Participates actively in departmental meetings to improve clinical programs and enhance processes. Shares clinical information and department procedure protocols during client site visits. Assists the FWA Team with new clinical programs and system enhancements. Follows all policies and procedures related to job clinical support as needed for special projects and other duties assigned by the Director, Compliance, FWA. Performs other duties as assigned to meet departmental objectives. Accurately and thoroughly investigates potential external fraud and abuse involving commercial and government lines of business, including substantiating referrals, case research, conducting onsite or desk audits, clinical reviews of medical records, interviewing witnesses, developing corrective action plans, managing disputes, and collaborating with law enforcement and regulatory agencies. Cooperates with fraud, waste and abuse efforts with external business partners. Reviews medical and pharmacy records, researches and investigates complex cases for the purpose of detecting fraud both internal and external involving submission/payment of claims and identifies FWA issues for follow‑up. Interprets a variety of documents including client contracts, group benefit structures, Workplan Policies and Procedures, governmental policies, and diverse regulatory and legal requirements. Works with the FWA Clinical Pharmacist to conduct thorough research and develop evidence for adjudication of identified FWA cases. Requests and analyzes data to identify fraudulent billing patterns and solves problems using professional judgment. Provides routine interaction, referrals, and coordination with Medicaid, CMS, NICB, MEDIC, local, state and federal law enforcement, and regulatory licensing boards. Monitors regulatory interactions with the network of providers, prescribers, and members. Prepares comprehensive reports of findings, documents cases for potential prosecution and civil settlement, and may review files or testify in court when required. Manages cases, prioritizes case load, maintains case logs, prepares records and status reports. Acts as primary point of contact with law enforcement in conjunction with the FWA Investigator. Prepares recommendations on preventive/corrective measures to deter future fraud. Supports other FWA personnel and analysts by providing medical information/expertise and performing clinical reviews of medical records. Contributes to the development of medical procedural guidelines, protocols, and employee training. Mentors staff and assists with training and coaching when necessary. Serves as a subject matter expert and liaison, representing non‑clinical staff in discussions with clients or other departments. Provides backup for Supervisors/Managers as needed and oversees the department, developing and administering policies, business processes, and quality standards. Establishes procedures to ensure compliance with state and federal FWA contracts and agreements. Client Responsibilities Provide excellent customer service skills and interpersonal communication skills (listening/verbal/written). Respond promptly to client needs and solicit client feedback to improve service. Meet commitments to clients and manage difficult or emotional client situations. Respond to requests for service and assistance from clients. Qualifications 4 - 6+ years of experience working in a lead investigative role. Proven experience in project development or management. Prior experience in Asset Protection/Investigations setting with compliance exposure preferred. Education and Experience Bachelor’s degree from an accredited college or university required; advanced degree highly desired. Computer Skills Strong proficiency with personal computers and MS Office (Word, Excel, Access, Outlook). Familiarity with relational database systems required. Knowledge of SQL software front‑ends such as MedOptimize required. Strong aptitude to learn and adapt to new programs; continuous improvement of data mining skills. Other Skills and Abilities Research development, methodologies, reporting, analysis, and publishing. Ability to balance a high volume of work & variety of tasks and prioritize urgent issues. Detail oriented, accurate and time‑management focused. Strong passion for providing service to customers (clients, members, other departments). Self‑starter; works independently and as part of a team. Can influence others, lead workgroups, and coordinate service requests throughout the organization. Can gather, document, and communicate business requirements and client specifications. Can understand and interpret contract language and negotiate favorable contract terms. Deep knowledge of the health benefits arena, preferably in pharmacy benefits management, Medicare Part D, Medicaid and health exchanges. Superior ability to determine state and federal fraudulent activity and compile necessary documentation for prosecution presentation. Explain and interpret findings to law‑enforcement authorities with clarity. Remains current on medical and pharmacy standards of care. Competencies Adaptability – Quickly adjusts to evolving situations, integrates new information, and implements necessary changes. Relationship Building and Networking – Maintains a network of diverse contacts, initiates collaborations, and helps others. Communication – Expresses self clearly and effectively in written and verbal interactions; uses active listening. Customer/Client Focus – Understands customer needs, interacts directly, takes responsibility for satisfaction, and follows up. Initiative – Gathers and analyzes information, assesses situations, identifies challenges and opportunities, and takes appropriate action. Integrity – Builds trust, tells the truth, aligns actions with stated values, and assigns credit appropriately. Interpersonal Effectiveness – Resolves conflicts efficiently, respects differences, and builds strong relationships. Physical Demands The position requires the employee to sit and talk or hear regularly, use hands for tasks, occasionally stand, walk, lift about 10 pounds, and requires close, distance, color, peripheral, and depth vision. Work Environment Occasional exposure to moving mechanical parts, fumes or airborne particles, toxic or caustic chemicals, and risk of electrical shock. Noise level usually moderate. Working Hours Exempt; may work beyond traditional hours, nights, weekends or holidays as required. Typical core business hours Monday‑Friday 8:00am‑5:00pm. Travel Occasional domestic travel required. Benefits Medical / Dental / Vision / Wellness Programs Paid Time Off / Company Paid Holidays Incentive Compensation 401(k) with Company match Life and Disability Insurance Tuition Reimbursement Employee Referral Bonus Equal Opportunity Employer Male/Female/Disabilities/Veterans OSHA/ADA. EEO statement: Equal Opportunity Employer. Reasonable accommodations may be made for individuals with disabilities. Disclaimer The above statements describe the general nature and level of work being performed, and are not an exhaustive list of all responsibilities, duties, and skills required. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel in this classification. #J-18808-Ljbffr