Become a part of our caring community and help us put health first
 

The Manager, Fraud and Waste conducts investigations of allegations of fraudulent and abusive practices. The Manager, Fraud and Waste works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.

The Manager of Fraud and Waste is responsible for overseeing a wide range of investigations and audits related to waste, abuse, and fraud. This role ensures that all audits comply with federal and state Medicaid fraud, waste, and abuse guidelines. The manager collaborates with law enforcement authorities to coordinate investigations and supervises the activities of the Special Investigations Unit (SIU) to ensure accurate and timely operational and final reviews. They gather evidence and documentation to support successful adjudication when necessary.  Additionally, the manager prepares detailed investigative and audit reports. Their decisions often involve resource allocation, project approaches, and tactical operations within their department. The role requires cross-departmental collaboration, conducting briefings and area meetings, and maintaining frequent contact with other managers across the department.

Use your skills to make an impact
 

Additional Job Description:

• Interpret audit results and assist health plan executives in developing appropriate action plans to address identified risks.
• Ensure compliance with all state and federal regulations regarding fraud and abuse.
• Respond to all legal inquiries, including subpoenas and court appearances.
• Attend federal CMS and state fraud meetings with other managed care organizations, as well as state and federal employees.

WORK STYLE: Remote/work at home with Up to 10-15% travel (local, regional, national) will be required

WORK HOURS: Core business hours are Monday-Friday, 8 hours/day, 5 days/week.

Required Qualifications

• Bachelor's degree in Accounting, Criminal Justice, Finance, Medical Professional, Economics, Operations Management or related field or equivalent. 7+ years of related compliance and/or special investigation experience in managed care or CMS.
  • Prior health insurance claims experience
  • Demonstrated formal or informal people management
  • Excellent PC skills (including MS, Excel and Access) required.
  • Excellent communication skills, written and verbal
  • Previous operational leadership and/or progressive business consulting experience
  • Strong organizational and project management skills
  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences
  • Proven FWA Managed Care (Medicaid) Investigative experience

Preferred Qualifications

• Minimum of two years of leadership experience
• CFE (Certified Fraud Examiner) or AHFI (Accredited Healthcare Fraud Investigator)

Additional Information

• Benefits starting day 1 of employment 
• Competitive 401k match  
• Generous Paid Time Off accrual  
• Tuition Reimbursement 
• Parental Leave 

WAH requirements:

•   Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
•    A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.  
•    Satellite and Wireless Internet service is NOT allowed for this role.
    A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Interview Format 

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
 

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview.  If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
 

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided.  Expect this type of interview to last anywhere from 5-10 minutes. Your recor