Risk Manager

Job Description

Job Description

We are looking for an experienced Risk Manager to support fraud, waste, and abuse oversight for a healthcare organization in Sunrise, Florida. This Long-term Contract position focuses on protecting program integrity through investigations, compliance monitoring, data analysis, and collaboration with regulatory and enforcement partners. The role is well suited to an individual who is detail oriented and can manage sensitive cases, interpret complex requirements, and drive recovery opportunities with accuracy and professionalism.

Responsibilities:
• Lead fraud, waste, and abuse oversight activities to strengthen program integrity and support healthcare risk management objectives.
• Build and maintain effective working relationships with Medicaid program integrity representatives, including participation in collaborative meetings and timely responses to inquiries.
• Direct investigative case management from initial referral through documentation, resolution, reporting, and recovery follow-up.
• Use data mining, claims analysis, and pattern review to identify suspicious billing activity, unusual utilization trends, and new investigation opportunities.
• Conduct detailed investigations involving providers, members, subcontractors, and other relevant parties while ensuring complete and well-supported case records.
• Prepare clear investigative summaries, audit findings, and regulatory reports covering all stages of case development and outcomes.
• Coordinate with compliance partners, public agencies, law enforcement, and oversight entities to support referrals, information requests, and enforcement actions.
• Monitor adherence to state and federal fraud prevention requirements and communicate applicable obligations to internal teams and external stakeholders.
• Support overpayment recovery efforts by identifying financial exposure, documenting findings, and working with appropriate parties to pursue resolution.
• Perform additional risk and compliance duties as needed to meet departmental priorities and business needs.• At least 1 year of experience in risk management, fraud investigation, compliance investigations, or healthcare program integrity.
• Background in healthcare fraud, anti-fraud operations, fraud analytics, or related investigative work within a regulated environment.
• Knowledge of risk analysis, risk management strategies, and compliance management practices.
• Ability to perform data mining and interpret claims or billing patterns to detect potential fraud, waste, or abuse.
• Familiarity with state and federal regulatory requirements tied to investigations, compliance functions, and reporting obligations.
• Strong due diligence, documentation, interviewing, and analytical skills with careful attention to detail.
• Ability to communicate findings clearly to providers, internal stakeholders, regulatory contacts, and external partners.
• Experience collaborating across compliance, audit, and investigative teams while managing multiple priorities effectively.