Fraud, Waste, and Abuse Program Manager

PacificSource Health Plans

FWA Program Manager at PacificSource overseeing fraud prevention efforts and compliance with health care regulations. Design and manage comprehensive FWA programs while collaborating with compliance officers.

Posted 7/15/2026full-timeRemote • Florida • 🇺🇸 United StatesSeniorLead💰 $83,310 - $145,793 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in designing and managing Fraud, Waste, and Abuse (FWA) programs, ensuring compliance with state and federal regulations while maximizing recoveries for Medicare and Medicaid claims. Proficient in developing policies, procedures, and tracking systems to effectively investigate and manage FWA complaints.

Highest-signal resume keywords

FWA Program ManagementFraud InvestigationsPayment Integrity ProcessesMedicare and Medicaid ComplianceFraud Examiner Certification

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Data MiningProcess DevelopmentRegulatory ReportingFWA Policy DevelopmentInvestigative TechniquesTracking System DevelopmentMonitoring and ReportingRecommendations to LeadershipWorkflow ManagementCompliance Analysis

Soft Skills

CollaborationIndependent ResearchCommunicationProblem-SolvingLeadership

Certifications & Qualifications

Fraud Examiner Certification

Industry Keywords

FraudWasteAbusePayment IntegrityHealth Care ClaimsFWA PreventionProgram Integrity CommitteeDisclosure StrategiesState and Federal RequirementsHealth Care Administration

About the role

Key responsibilities & impact

Design, implement, and manage the company’s FWA Program.
Provide expertise to staff in developing processes for tracking, investigating, and managing suspected FWA complaints.
Analyze, report and monitor the FWA prevention efforts and provide recommendations to leadership.
Track and report company activities to ensure compliance with state and federal FWA requirements.
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.
Develop and maintain an FWA log and tracking system.
Proactively and independently research FWA issues and effectively employ investigative resources/techniques.
Maximize recoveries and avoidance for Medicare and Medicaid claims payments.
Develop disclosure strategies for potential fraud activities to various agencies.

Requirements

What you’ll need

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.
Fraud examiner certification preferred.

Benefits

Comp & perks

Flexible telecommute policy
Medical, vision, and dental insurance
Incentive program
Paid time off and holidays
401(k) plan
Volunteer opportunities
Tuition reimbursement and training
Life insurance
Options such as a flexible spending account