Fraud Waste and Abuse (FWA) Program Manager

PacificSource Health Plans•Boise, ID

1d•$83,310 - $145,793

About The Position

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! 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.

Requirements

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.
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.

Nice To Haves

Master’s degree in business, management, or health care administration preferred.
Fraud examiner certification preferred.

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.
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.