Manager - Fraud Waste and Abuse Negotiations

Manager Fraud, Waste, and Abuse (FWA) Negotiations

The Manager Fraud, Waste, and Abuse (FWA) Negotiations is responsible for leading and optimizing the organization's claim control strategies. The role provides oversight and direction for identifying and mitigating fraud, waste and abuse across international claims while ensuring cost containment and operational efficiency. The manager leads a team of specialists, drives continuous improvement in negotiation practices and partners cross-functionally to enhance tools, processes and provider strategies. This role plays a critical part in reducing unnecessary medical spending and advancing our mission to make healthcare more affordable.

Responsibilities

• Lead a team of individuals responsible for negotiating healthcare claims with non-contracted providers and facilities around the world.
• Optimize performance with attention to savings realization, inventory management, process design and documentation, KPI development and reporting.
• Identify opportunities or gaps in current processes and implement solutions to improve team performance and customer experience.
• Cultivate relationships with high volume providers and key business partners.
• Coordinate directly with representatives from BCBS Home plans for Global Core Negotiations.
• Collaborate with the Provider Relations department to identify network expansion opportunities and evaluate fee schedule proposals.
• Coordinate activities across departments (ex. FWA, Clinical, Provider Finance, Customer Service, Claims) and external entities (ex. home plans).
• Develop capacity models and business cases to ensure support for growth.
• Ensure timely resolution and notification of escalated cases.
• Track activity and produce reports to measure impact and document actions.
• Support cross-functional projects and initiatives as a subject matter expert as needed.
• Develop and deliver training on key skills or relevant case studies.
• Support commercial teams in client meetings and finalist presentations as needed.
• Contact external 3rd parties as needed through outbound call or email to obtain additional information or verify claim information.
• Validate accuracy of claim charges and initial processing decisions.
• Perform online research to fill in gaps in existing tools and understanding.

Requirements

• 5+ years of insurance industry or other relevant experience required.
• College degree or equivalent experience.
• Strong working knowledge of international health insurance claims.
• Knowledge of US Domestic health insurance claims is a plus.
• Prior experience identifying or investigating fraud, waste, and abuse is highly valued.
• Multi-lingual strongly preferred.
• Strong attention to detail and problem-solving skills.
• Excellent written and verbal communication skills.
• Demonstrated ability to build relationships and negotiate positive outcomes.
• Prior experience leading high performing teams in a fast-paced environment strongly preferred.
• Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
• Ability to deal with ambiguity and drive for resolution.
• Willingness and ability to learn and apply new skills.
• Multi-lingual strongly preferred.
• Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

Working Conditions

• Flexibility to work in an office and/or at-home, remote office environment.
• Schedule flexibility is occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
• Physical Demands: Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.

This job description reflects management's assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.