Fraud, Waste & Abuse Manager- Special Investigation Unit (S.I.U.)

The Manager, Fraud, Waste & Abuse (FWA) provides leadership and oversight of the FWA area. The position involves the management of the FWA Program in compliance with CMS, AHCA and other regulatory state and federal guidelines. 
 

KEY RESPONSIBILITIES:

• Lead and oversee the FWA Program and work plan 
• Lead special investigations 
• Research, investigate and report fraud, waste and abuse cases 
• Utilize internal system, external platforms and appropriate state and federal guidelines to research potential FWA 
• Partner with the Internal Audit and Recovery Unit to help address FWA
• Develop, implement and track corrective action plans 
• Participate in payment integrity initiatives
• Responsible for the FWA Quarterly and Annual Reports 
• Responsible for ensuring compliance and external reporting to CMS, AHCA, and other regulators
• Review and audit high-dollar and complex claim disputes
• Communicate with stakeholders and recommend process improvements leveraging analytics, automation, and AI-powered tools 
• Educate providers, vendors and members on how to identify and report FWA cases
• Develop and mentor a high-performing, accountable team, fostering a culture of professional growth and operational excellence
• Work closely with the Compliance Team  
• Collaborate with other departments to integrate best practices and enhance overall FWA and operational solutions 
• Meet performance metrics and goals established for the position
• Performs additional duties and responsibilities as assigned by management

The above statement reflects the general duties considered necessary to describe the principal functions of the job identified and shall not be considered as a detailed description of all work requirement inherent to the position.

QUALIFICATIONS:

• Minimum of 10 years of FWA, healthcare and/or Medicare Advantage experience; strong knowledge of Medicare Advantage, CMS and AHCA regulatory requirements 
• Expertise in FWA, Special Investigations, claims processing, coding and medical terminology
• Outstanding investigative and research skills
• Proven track record in strategic planning, operations and process improvement
• Able to thrive in a complex, high-pressure environment
• Bachelor’s degree in Business, Healthcare Administration, or a related field
• High-degree of computer literacy and advanced Excel spreadsheets for operational data analysis and reporting