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 regulatory agencies as needed.
• Implement and maintain payment integrity policies, procedures, workflows, and operational controls.
• Ensure compliance with applicable federal and state regulations, CMS requirements, contractual obligations, and internal policies.
• Serve as a primary operational liaison between Payment Integrity, Compliance, Claims Operations, Provider Relations, Finance, and Special Investigations functions.
• Coordinate day to day operational activities with external vendors supporting audit, recovery, analytics, and fraud detection programs and monitor adherence to established service levels.
• Review audit findings, recovery opportunities, and investigative outcomes to ensure consistency, accuracy, and adherence to established standards.
• Support preparation and submission of regulatory reporting requirements related to fraud, waste, abuse, and payment integrity activities.
• Participate in internal and external audits and assist with corrective action planning and implementation.
• Identifying emerging risks, payment vulnerabilities, billing trends, and opportunities for program improvement and escalate recommendations to leadership.
• Lead or participate in departmental projects, process improvement initiatives, and cross-functional workgroups.
• Actively participate as a key member of management and leadership meetings.
• Represent Payment Integrity on internal committees and workgroups as assigned.
• Coordinate business activities by maintaining collaborative partnerships with key departments.
• Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees.
• Actively participate as a key team member in department meetings.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.

Supporting Responsibilities:

• Participate in compliance and operational initiatives as needed.
• Assist with training and education efforts related to payment integrity and FWA prevention.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of 4 years of senior-level healthcare operations, payment integrity, fraud prevention, claims auditing, claims administration, or related experience required. Prior supervisory experience preferred.

Education, Certificates, Licenses: Bachelor's degree 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.

Knowledge: Knowledge of healthcare claims processing, reimbursement methodologies, coding systems, and payment integrity concepts. Knowledge of fraud, waste, and abuse regulations and investigative practices. Understanding of Medicare, Medicaid, and commercial health plan regulatory requirements. Knowledge of ICD-10, CPT, HCPCS, DRG, and related reimbursement methodologies. Strong analytical, problem-solving, and decision-making skills. Ability to interpret data, identify trends, and develop operational recommendations. Ability to communicate effectively with leadership, regulators, providers, vendors, and cross-functional business partners.

Skills: Communication (written/verbal), Listening (active), Critical thinking, Collaboration, Organizational skills/Planning and Organization, Accountable leadership, Influencing, Decision-making.

Competencies

Building Trust

Building a Successful Team

Aligning Performance for Success

Building Customer Loyalty

Building Strategic Work Relationships

Continuous Improvement

Decision Making

Facilitating Change

Leveraging Diversity

Driving for Results

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Skills:
Accountable leadership, Collaboration, Communication (written/verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills/Planning and Organization

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:
$83,310.45 - $145,793.28

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.