Manager – Prepayment Fraud, Waste, and Abuse Operations

This is a fully remote position, open to applicants in California.

📋 Description

• Oversee and enhance operations related to Prepayment Fraud, Waste, and Abuse.

• Guarantee quality, efficiency, punctuality, compliance, and achievement of contractual performance goals.

• Lead, nurture, and improve team performance through coaching, performance management, workforce planning, training, and employee growth.

• Act as a point of escalation for intricate investigations, policy clarification, and high-risk matters.

• Develop and uphold investigative governance, documentation protocols, and case review processes.

• Track operational performance, quality results, investigative patterns, and emerging risks associated with fraud, waste, and abuse.

• Recognize process deficiencies, mitigate risks, and promote data-driven recommendations and ongoing improvement initiatives.

• Collaborate with clients, medical advisors, compliance teams, legal representatives, and various stakeholders.

• Spearhead the implementation of regulatory modifications, business requirements, system upgrades, and operational enhancements.

⛳️ Requirements

• A minimum of 5 years of experience in healthcare operations, program integrity, fraud, waste and abuse investigations, claims analysis, payment integrity, auditing, compliance, or a similar healthcare domain.

• At least 2 years of leadership experience overseeing investigative, analytical, healthcare operations, or program integrity teams.

• In-depth understanding of healthcare regulations, billing standards, claims processing, fraud, waste and abuse detection techniques, and program integrity operations.

• Experience in analyzing claims, provider billing activities, authorization records, healthcare data, and investigative results.

• Demonstrated capability to lead complex operational projects, manage conflicting priorities, resolve issues, and implement process enhancements.

• Exceptional analytical, communication, stakeholder management, and relationship-building abilities.

• Candidates must live within an hour's commute of California's State Capital.

🏝️ Benefits

• Flexible work arrangements.

• Opportunities for learning and career advancement.

• Flexible vacation policy.

• 401(k) employer matching.

• Comprehensive health coverage.

• Educational support.

• Leadership and technical development academies.