Senior Fraud, Waste and Abuse Specialist

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

📋 Description

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

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

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

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

• Act as the primary contact with CMS, MEDIC, OHA, Medicaid Fraud Units, and other supervisory agencies.

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

• Monitor regulatory requirements and suggest program improvements.

• Assist with internal and external audits and 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 design prospective and retrospective monitoring strategies.

• Provide recommendations to enhance program efficiency and financial recoveries.

• Create and deliver FWA training and awareness initiatives.

• Lead or coordinate activities for 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 issues.

⛳️ Requirements

• A minimum of 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 efforts.

• Preferred experience working 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 required.

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

🏝️ Benefits

• Health insurance

• 401(k) matching

• Flexible working hours

• Paid time off

• Professional development opportunities