Payment Integrity and Fraud, Waste and Abuse Team Lead

Job description

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths. The Payment Integrity and Fraud, Waste and Abuse (FWA) Team Lead is responsible for overseeing the daily operations of PacificSource's Payment Integrity and FWA programs. This role provides leadership for Payment Integrity and FWA activities while supporting the development and execution of pre-payment and post-payment initiatives designed to ensure payment accuracy, regulatory compliance, and responsible stewardship of healthcare resources. The Team Lead serves as a subject matter expert in payment integrity operations, fraud prevention, audit activities, provider recoveries, and regulatory requirements. This position works closely with Claims, Compliance, Finance, Provider Relations, and external vendors to identify opportunities for cost avoidance, overpayment recovery, process improvement, and program effectiveness. Essential Responsibilities: * Provide direct supervision, coaching, performance management, and professional development for assigned Payment Integrity and FWA staff. * Supervise and direct payment integrity claims adjustment activities, ensuring timely and accurate implementation of claim corrections, recoveries, and financial adjustments. * Oversee recovery inventory management and ensure identified overpayments, audit findings, and recovery opportunities are appropriately processed, tracked, and resolved. * Coordinate daily work activities, workload prioritization, inventory management, and resource allocation across payment integrity functions. * Support the execution and on-going operations of pre-payment and post-payment payment integrity programs, including audits, claims reviews, recoveries, and fraud prevention activities. * Oversee the investigation, tracking, documentation, and resolution of potential fraud, waste, and abuse referrals and cases. * Monitor payment integrity performance metrics and recovery results and prepare reports for leadership, compliance committees, and regulat To view the full job description please use the link below. https://www.aplitrak.com/?adid=YmJnZW5lcmljLjM3ODU3Ljg3NjRAcGFjaWZpY3NvdXJjZWNvbXAuYXBsaXRyYWsuY29t