Fraud, Waste, and Abuse Program Manager

PacificSource Health Plans

FWA Program Manager at PacificSource, driving compliance and integrity within healthcare operations. Leading the development and implementation of FWA programs and auditing processes.

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

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in developing and maintaining Fraud, Waste, and Abuse (FWA) programs, including policy implementation, regulatory reporting, and data analysis. Proven ability to collaborate with oversight agencies and lead investigations to maximize recoveries in Medicare and Medicaid claims.

Highest-signal resume keywords

Fraud, Waste, And Abuse InvestigationsPayment Integrity ProcessesData Mining And AnalysisRegulatory Agency ReportingMedicare And Medicaid Programs

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

FWA Policy DevelopmentFWA Program ImplementationData AnalysisInvestigative TechniquesAudit And Monitoring PlanningFWA ReportingRegulatory ComplianceClaims Payment RecoveryTracking System DevelopmentTraining Presentation Development

Soft Skills

CollaborationIndependent ResearchCommunicationProblem-SolvingLeadership

Certifications & Qualifications

Fraud Examiner Certification

Industry Keywords

Health Care AdministrationCMS ReportingOHA Medicaid Fraud UnitCorporate ComplianceProgram Integrity Committee

About the role

Key responsibilities & impact

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
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

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