Senior Fraud, Waste and Abuse (FWA) Specialist

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 Senior Fraud, Waste and Abuse (FWA) Specialist serves as the organization's subject matter expert responsible for supporting and advancing PacificSource's Payment Integrity and FWA programs. This role provides operational expertise in program development, compliance oversight, fraud prevention, payment integrity initiatives, regulatory reporting and audit management. This position leads program administration activities, partners with operational teams and regulatory agencies, and develops processes that strengthen the organization's ability to detect, prevent, investigate, recover, and report fraud, waste, abuse, and payment integrity concerns. Essential Responsibilities: * Support the development and maintenance of the Payment Integrity and FWA program framework. * Develop, implement, and maintain program policies, workflows, procedures, and controls. * Maintain centralized tracking and reporting systems for investigations, recoveries, referrals, and regulatory activities. * Coordinate annual audit, monitoring, and work plan activities. * Serve as primary liaison with CMS, MEDIC, OHA, Medicaid Fraud Units, and other oversight agencies. * Ensure timely and accurate submission of FWA and payment integrity reporting requirements. * Monitor regulatory requirements and recommend program enhancements. * Support internal and external audits and corrective action initiatives. * Analyze program performance, recovery results, and fraud prevention outcomes. * Identify fraud schemes, payment vulnerabilities, and emerging risks. * Collaborate with analytics teams to develop prospective and retrospective monitoring strategies. * Develop recommendations to improve program effectiveness and financial recoveries. * Develop and deliver FWA training and awareness programs. * Chair or coordinate Program Integrity Committee activities. * Prepare reports and presentations for leadership, compliance committees, and th To view the full job description please use the link below. https://www.aplitrak.com/?adid=YmJnZW5lcmljLjM3MDc3Ljg3NjRAcGFjaWZpY3NvdXJjZWNvbXAuYXBsaXRyYWsuY29t