Senior Fraud, Waste and Abuse Specialist

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

📋 Description

• Assist in the development and upkeep of the Payment Integrity and Fraud, Waste, and Abuse (FWA) program framework.

• Create, implement, and sustain program policies, workflows, procedures, and controls.

• Manage centralized systems for tracking and reporting investigations, recoveries, referrals, and regulatory activities.

• Oversee annual audits, monitoring, and work plan activities.

• Act as the main point of contact with CMS, MEDIC, OHA, Medicaid Fraud Units, and other regulatory agencies.

• Guarantee the timely and accurate submission of FWA and payment integrity reporting obligations.

• Monitor regulatory standards and propose enhancements to the program.

• Assist with both internal and external audits, as well as corrective action initiatives.

• Evaluate program performance, recovery outcomes, and fraud prevention results.

• Detect fraud schemes, payment vulnerabilities, and emerging risks.

• Collaborate with analytics teams to devise both prospective and retrospective monitoring strategies.

• Formulate suggestions to enhance program efficacy and financial recoveries.

• Design and deliver FWA training and awareness initiatives.

• Lead or coordinate activities of the Program Integrity Committee.

• Compile reports and presentations for leadership, compliance committees, and the Board.

• Serve as an internal expert on FWA and Payment Integrity topics.

⛳️ Requirements

• At least 5 years of experience in fraud, waste, and abuse (FWA), payment integrity, healthcare compliance, claims auditing, claims analysis, or related healthcare operations roles.

• Required experience in analyzing healthcare claims data, identifying potential payment integrity risks, and supporting FWA monitoring, reporting, or compliance activities.

• Preferred experience with Medicare and/or Medicaid programs.

• Highly desirable experience in data mining, analytics, regulatory reporting, or collaboration with investigative teams.

• A Bachelor’s degree in business, management, healthcare administration, or a related field is mandatory.

• Candidates holding an associate’s degree with 2 years of relevant experience, or a high school diploma with 4 years of relevant experience, will also be considered, in addition to the required minimum years of work experience.

🏝️ Benefits

• Flexible telecommuting 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