Manager, Payment Integrity
Core
Develop and manage strategic fraud, waste, and abuse (FWA) activities to ensure integrity and compliance in billing and claims payment for health plans.
Role type
Manager, Payment Integrity (Fraud, Waste, and Abuse)
Builds
Customized fraud plans, educational materials, and FWA programs for state/federal readiness reviews.
Domain
Healthcare / Medical Claims / Compliance
Required skills
Medical claim investigation, compliance, fraud and abuse analysis, medical terminology, team leadership, policy development, report preparation
Preferred skills
Managed care environment experience, hiring and performance management, medical records or coding license
Technologies
None explicitly stated
Responsibilities
Monitor business processes and systems for billing and claims integrity; lead teams to investigate fraud, waste, and abuse referrals; develop customized fraud plans; prepare and present FWA programs to state/federal personnel; review post-payment cases for refunds; prepare saving reports.
Seniority
Manager, hands-on leadership
