Fraud, Waste, and Abuse (FWA) Program Manager

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The FWA Program Manager will be primarily responsible for the design, implementation, and management of the company’s FWA Program, providing expertise to staff in developing processes for tracking, investigating, and managing suspected FWA complaints. The role will analyze, report and monitor the FWA prevention efforts and provide recommendations to leadership on matters related to FWA compliance. The program manager will track and report company activities to ensure compliance with state and federal FWA requirements.

Essential Responsibilities

• In collaboration with the Corporate Compliance Officer and other business unit leaders, 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 which will outline and detail the annual FWA audit and monitoring plan.
• Develop and maintain an FWA log and tracking system.
• Proactively and independently researches FWA issues and effectively employ investigative resources/techniques.
• Maximize the recoveries and avoidance for Medicare and Medicaid claims payments with a demonstrated ability to achieve results.
• Work to develop prospective and retrospective fraud and abuse detection, investigation, recovery and avoidance through the use of data sources for data mining and analytics to proactively seek out outlying claims activities and investigate for fraud, waste, and abuse.
• Develop, translate, and execute strategies or functional/operational objectives for the company with regard to fraud, waste, and abuse.
• Responsible for notification of MEDIC of potential fraud activities.
• Responsible for notification of state and other federal agencies of potential fraud activities.
• Assist in the development and presentation of FWA training presentations.
• Serve as primary point of contact for external oversight agencies to include the MEDIC and OHA Medicaid Fraud Unit.
• Serve as a member of the Corporate Compliance Committee reporting on FWA matters across all lines of business.
• Responsible for creating and presenting FWA reports to the Audit and Compliance Committee of the Board.
• Manage and oversee the preparation and submission of FWA regulatory reporting requirements to CMS and OHA.
• Regularly attend fraud related meetings with OHA.
• Responsible for oversight, management, development, implementation, and communication of the FWA program.

Supporting Responsibilities

• Participate in compliance initiatives as needed.
• Perform day-to-day tasks of the compliance department as needed.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: 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.

Education, Certificates, Licenses: Bachelor’s degree in business, management, health care administration or other related field or Associate’s degree and equivalent work experience required. Master’s degree in business, management, or health care administration preferred. Fraud examiner certification preferred.

Knowledge: Ability to gain a thorough understanding of PacificSource compliance initiatives. Ability to organize large projects that involve working with multi-functional teams under strict deadlines. Ability to build a program from the ground up by developing people, process, and technology mechanisms to support the program. Ability to communicate effectively with all levels of the organization both verbally and in writing. Working knowledge of medical terminology. Ability to work under time pressures, and to deal with emotional situations.

Competencies

Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills

Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range

$83,310.45 - $145,793.28

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.

• We are one team working toward a common goal.

• We are each responsible for customer service.

• We practice open communication at all levels of the company to foster individual, team and company growth.

• We actively participate in efforts to improve our many communities-internally and externally.

• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.