Manager, Fraud, Waste & Abuse (FWA) Job at DOCTORS HEALTHCARE PLANS, INC., Coral Gables, FL

c2NBWTM3aEVpbWVqZjJyTXlHa3I1c1FKc3c9PQ==
  • DOCTORS HEALTHCARE PLANS, INC.
  • Coral Gables, FL

Job Description

The Manager, Fraud, Waste & Abuse (FWA) provides leadership and oversight of the FWA area. The position involves the management of the FWA Program in compliance with CMS, AHCA and other regulatory state and federal guidelines. 

 

KEY RESPONSIBILITIES:

  • Lead and oversee the FWA Program and work plan 
  • Lead special investigations 
  • Research, investigate and report fraud, waste and abuse cases 
  • Utilize internal system, external platforms and appropriate state and federal guidelines to research potential FWA 
  • Partner with the Internal Audit and Recovery Unit to help address FWA
  • Develop, implement and track corrective action plans 
  • Participate in payment integrity initiatives
  • Responsible for the FWA Quarterly and Annual Reports 
  • Responsible for ensuring compliance and external reporting to CMS, AHCA, and other regulators
  • Review and audit high-dollar and complex claim disputes
  • Communicate with stakeholders and recommend process improvements leveraging analytics, automation, and AI-powered tools 
  • Educate providers, vendors and members on how to identify and report FWA cases
  • Develop and mentor a high-performing, accountable team, fostering a culture of professional growth and operational excellence
  • Work closely with the Compliance Team  
  • Collaborate with other departments to integrate best practices and enhance overall FWA and operational solutions 
  • Meet performance metrics and goals established for the position
  • Performs additional duties and responsibilities as assigned by management

The above statement reflects the general duties considered necessary to describe the principal functions of the job identified and shall not be considered as a detailed description of all work requirement inherent to the position.

QUALIFICATIONS:

  • Minimum of 10 years of FWA, healthcare and/or Medicare Advantage experience; strong knowledge of Medicare Advantage, CMS and AHCA regulatory requirements 
  • Expertise in FWA, Special Investigations, claims processing, coding and medical terminology
  • Outstanding investigative and research skills
  • Proven track record in strategic planning, operations and process improvement
  • Able to thrive in a complex, high-pressure environment
  • Bachelor’s degree in Business, Healthcare Administration, or a related field
  • High-degree of computer literacy and advanced Excel spreadsheets for operational data analysis and reporting
Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

No Third Party Agencies or Submissions Will Be Accepted.   

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP   

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

Job Tags

Full time, Contract work,

Similar Jobs

Prime + Proper - Nashville

Executive Chef Job at Prime + Proper - Nashville

 ...At Heirloom Hospitality Group, our purpose is Cultivating Relationships & Experiences through the fanatic pursuit of Enlightened Hospitality ." We are dedicated to creating an environment that promotes creativity, passion, and a genuine sense of community. We are... 

Ginas Tech Jobs

Junior Salesforce Administrator Job at Ginas Tech Jobs

 ...Junior Salesforce Administrator, Chicago, IL This Junior Salesforce Administrator opportunity offers a clear path for career growth within Salesforce administration. The Junior Salesforce Administrator will have the opportunity to gain hands-on experience, earn additional... 

NoGigiddy

Entry-Level Remote Sales Development Representative (20 - 27 per hour) Job at NoGigiddy

 ...NoGigiddy is seeking a motivated and energetic Entry-Level Remote Sales Development Representative (SDR) to join our remote team. In this role, you will be responsible for generating and qualifying leads, setting up meetings for the sales team, and supporting our sales... 

Atomic HR

Paid Summer Internship for Law School Students L1/L2 |... Job at Atomic HR

 ...based organization that provides specialized legal services for immigration matters. They...  ...advocating for immigrants' rights. This summer, they are looking for a motivated Immigration Legal Analyst and Copywriter Summer Intern with a focus on legal research and writing... 

Sarasota Manatee Airport Authority

Firefighter - Paramedic Job at Sarasota Manatee Airport Authority

 ...SARASOTA MANATEE AIRPORT AUTHORITY JOB TITLE: Firefighter - Paramedic REPORTS TO: Fire Captain DEPARTMENT : Airport Fire Department FLSA STATUS : Non-Exempt Starting Salary: $59,302 Salary Grade Range as of October 1, 2025: $67,012 - $100,5...