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 the Board.
- Serve as an internal subject matter expert on FWA and Payment Integrity matters.
Supporting Responsibilities: - Participate in compliance initiatives as needed.
- Perform day-to-day tasks of the compliance department as needed.
- 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 PROFILEWork Experience: Minimum of 5 years of experience in fraud, waste, and abuse (FWA), payment integrity, healthcare compliance, claims auditing, claims analysis, or related healthcare operations functions. Experience analyzing healthcare claims data, identifying potential payment integrity risks, and supporting FWA monitoring, reporting, or compliance activities required. Experience working with Medicare and/or Medicaid programs preferred. Experience with data mining, analytics, regulatory reporting, or collaboration with investigative teams is highly desirable.
Education, Certificates, Licenses: Bachelor's degree in business, management, health care administration or related field 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: Ability to gain a thorough understanding of PacificSource compliance initiatives. Ability to organize large projects that involve working with multi-functional teams under strict deadlines. Working knowledge of fraud, waste, and abuse (FWA) concepts, payment integrity practices, healthcare claims processing, and Medicare and Medicaid requirements. Ability to analyze claims data, identify trends and potential risks, and prepare reports and recommendations. Strong analytical and organizational skills. Working knowledge of medical terminology and healthcare reimbursement processes. Ability to collaborate effectively with internal stakeholders and maintain confidentiality when handling sensitive information. Ability to communicate effectively with all levels of the organization both verbally and in writing. Working knowledge of medical terminology. Ability to work under pressure, deadlines, and to deal with emotional situations.
Competencies Adaptability
Building Customer Loyalty
Building Strategic Work Relationships
Building Trust
Continuous Improvement
Contributing to Team Success
Planning and Organizing
Work Standards
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Skills:Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork
Compensation DisclaimerThe 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: $65,296.83 - $111,004.62
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.
