Program Manager, Fraud, Waste and Abuse

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

📋 Description

• Lead initiatives in Fraud, Waste & Abuse (FWA) and Program Integrity from strategy formulation to implementation, ensuring adherence to regulatory standards and operational excellence.

• Foster collaboration across various functions to create, implement, and enhance processes, systems, controls, and governance frameworks.

• Examine claims, provider, member, and audit data to uncover fraud patterns, billing irregularities, financial vulnerabilities, and recovery prospects.

• Collaborate with analytics teams to formulate detection strategies, business rules, dashboards, and investigative workflows.

• Supervise testing, quality assurance, and user acceptance activities to confirm that solutions align with business and compliance needs.

• Assist in audits and investigations through data analysis, reviewing documentation, gathering evidence, and providing actionable recommendations.

• Recognize operational risks and opportunities for process enhancements to improve program efficiency and results.

• Compile executive-level reports and insights regarding program performance, audit outcomes, investigation findings, and emerging risks.

• Offer leadership, mentorship, and subject matter expertise to analysts, auditors, investigators, and implementation teams.

• Act as a reliable partner to clients, regulators, vendors, and internal stakeholders, promoting accountability and ongoing improvement.

⛳️ Requirements

• Bachelor’s degree in healthcare administration, pharmacy, nursing, business, public administration, criminal justice, information systems, analytics, or a related field; equivalent relevant experience may be considered.

• A minimum of eight years of progressively responsible experience in healthcare program management, program integrity, FWA, payment integrity, special investigations, compliance, auditing, claims operations, or a related field.

• Proven experience in leading complex, cross-functional implementations from requirements gathering and design through testing, deployment, and operational transition.

• Demonstrated ability to develop policies, procedures, process designs, test cases, user acceptance testing materials, audit workpapers, and executive-level reports.

• Solid understanding of healthcare claims, provider billing, audit methodologies, investigative practices, evidence documentation, and overpayment identification.

• Familiarity with relevant federal and state healthcare program integrity requirements, including Medicare and/or Medicaid regulations.

• Exceptional analytical, critical-thinking, facilitation, project leadership, written communication, and presentation abilities.

• Capability to manage multiple priorities, exercise sound judgment, safeguard confidential information, and collaborate effectively with both technical and non-technical stakeholders.

• Willingness to travel for field audits, client meetings, or implementation activities as business needs dictate.

• Experience in supporting Medicaid, Medicare, managed care, pharmacy benefit management, or government healthcare programs.

• Proficiency in claims analytics, data visualization, audit or case-management platforms, and structured defect or requirements-management tools.

• Possession of professional certifications such as Certified Fraud Examiner, Accredited Health Care Fraud Investigator, Certified in Healthcare Compliance, Certified Internal Auditor, Project Management Professional, or an equivalent credential.

🏝️ Benefits

• Work flexibility

• Learning and career development

• Technical credentials and certifications

• Generous, flexible vacation policy

• Educational assistance

• Leadership and technical development academies

• 401(k) employer match

• Comprehensive health benefits

• Opportunities to travel through your work (0-25%)