Senior Fraud, Waste and Abuse Specialist

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

📋 Description

• Assist in the development and upkeep of the Payment Integrity and FWA program framework.

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

• Oversee centralized tracking and reporting systems for investigations, recoveries, referrals, and regulatory actions.

• Organize annual audit, monitoring, and work plan activities.

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

• Ensure the prompt and precise submission of FWA and payment integrity reporting obligations.

• Monitor regulatory requirements and suggest enhancements to the program.

• Aid in internal and external audits and corrective action processes.

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

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

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

• Formulate recommendations to enhance program efficiency and financial recoveries.

• Create and present FWA training and awareness initiatives.

• Lead or coordinate the activities of the Program Integrity Committee.

⛳️ Requirements

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

• Experience in analyzing healthcare claims data, spotting potential payment integrity risks, and supporting FWA monitoring, reporting, or compliance tasks is essential.

• Experience with Medicare and/or Medicaid programs is preferred.

• Background in data mining, analytics, regulatory reporting, or collaboration with investigative teams is highly beneficial.

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

• Candidates possessing an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, alongside the required minimum years of work experience will also be considered.

• Strong analytical and organizational abilities.

🏝️ Benefits

• Health insurance

• 401(k) matching

• Paid time off

• Professional development opportunities

• Flexible work arrangements