Fraud, Waste, and Abuse Investigations Manager

• Fraud, Waste, and Abuse Investigations Manager
• Exemption Status: United States of America (Exempt)

Job Description

Summary

The Fraud, Waste, and Abuse Investigations Manager handles the operational activities related to Pharmacy Compliance and FWA.

This position requires partnership and collaboration with a cross‑functional group of leaders and excellence in program management, interpersonal communication, and relationship building.

Primary Responsibilities

• Responsible for fraud and abuse detection activities for the state‑defined PBA programs, including the Fraud and Abuse Compliance Plan, and day‑to‑day provider investigation inquiries.
• Utilize prescription and medical claim data to generate clinical recommendations according to “Global” Drug Utilization Review protocols.

Provide recommendations on gaps in care, high‑risk medications, compliance and adherence, drug interactions, therapeutic substitution, and generic substitution.

• Participate actively in departmental meetings to improve clinical programs and processes.

Share clinical information and department procedures during client site visits and assist the FWA team with new clinical programs and system enhancements.

• Under the guidance of FWA Management, conduct accurate and thorough investigations of potential external fraud and abuse involving commercial and government lines of business.

Substantiate referrals, perform case research and planning, conduct onsite or desk audits, review medical records for billing accuracy, interview witnesses, develop corrective action plans, manage disputes, and collaborate with law enforcement and regulatory agencies.

• Maintain relationships with Medicaid, CMS, NICB, MEDIC, local, state, and federal law enforcement and regulatory licensing boards; monitor regulatory interactions with the provider network.
• Prepare comprehensive reports of findings and develop cases for potential prosecution and civil settlement.

Provide file reviews and testify in court or credentialing adjudication committees as needed.

• Manage cases, prioritize workload, maintain case logs, and prepare status reports.
• Act as primary point of contact with law enforcement for assigned cases in conjunction with the FWA investigator.
• Interpret data analyses, identify trends, and report findings to stakeholders.
• Prepare recommendations on preventive and corrective measures to deter future fraud.
• Support other FWA personnel by providing medical expertise and performing clinical reviews of medical records for other cases.
• Contribute to development of medical procedural guidelines, protocols, and employee training; stay informed on state and federal health care fraud laws.
• Demonstrate high standards of integrity, uphold the company’s mission and values, and adhere to the corporate code of conduct.
• Maintain member privacy in accordance with corporate and regulatory privacy rules.
• Suggest process improvements and participate in solving complex issues.
• Mentor staff and assist with training and coaching when necessary.
• Serve as subject matter expert and liaison for non‑clinical staff in client and internal department discussions.
• Act as an internal auditor/peer reviewer for new investigative staff when required.
• Provide backup for supervisors or managers as needed.
• Oversee day‑to‑day department operations, develop and administer policies, business processes, and quality standards; assist in developing and managing departmental policies and procedures.
• Establish procedures to ensure compliance with state and federal FWA contracts and agreements.
• Ensure deliverables meet quality levels expected by internal departments and external clients.
• Assist in coordinating all contracting efforts with outside vendors that support provider audits, credentialing, and FWA.
• Define standards to support department‑wide goals and ensure consistent execution of projects, including planning, execution, effectiveness, standards, escalation, and investigation management.
• Oversee operations between BA/IT, Pharmacy Compliance, FWA, and FIST to ensure timely project delivery and regulatory compliance.
• Supervisory Responsibilities

No supervisory responsibilities.

Client Responsibilities

This internal and external client‑facing position requires excellent customer service and interpersonal communication skills (listening, verbal, written).

Respond promptly to client needs, solicit feedback to improve service, meet commitments, and manage difficult or emotional client situations.

Qualifications

Education and/or

Experience: Bachelor’s degree from an accredited institution required; advanced degree preferred.

Four to six years’ experience in a lead investigative role, proven experience in project development or management, and prior experience in asset protection or compliance preferred.

Computer

Skills: Proficiency with personal computers and MS Office (Word, Excel, Access, Outlook).

Familiarity with relational database systems and SQL; knowledge of Med Optimize.

Ability to learn new programs and develop data‑mining skills.

Certificates, Licenses, Registrations: None required.

• Other Skills and Abilities
• Working knowledge of research methods, reporting, analysis, and publishing.
• Ability to balance a high volume of work and prioritize urgent issues.
• Detail orientation, accuracy, and time management.
• Passion for providing exceptional service to customers and internal stakeholders.
• Self‑starter who can work independently and collaborate effectively.
• Influence others, lead workgroups, and coordinate service requests across the organization.
• Gather, document, and communicate business requirements and client specifications.
• Understand contract language and negotiate favorable terms.
• Deep knowledge of the health benefits arena, preferably in pharmacy benefits management, Medicare Part D, Medicaid, and health exchanges.
• Expertise in identifying state and federal fraudulent activity and compiling documentation for prosecution.
• Stay current with medical and pharmacy standards of care.
• Reasoning Ability

Ability to solve practical problems and manage situations with limited standardization; interpret written, oral, diagrammatic, or schedule instructions.

Mathematical Skills

Ability to apply probability, statistical inference, geometry, trigonometry, fractions, percentages, ratios, integrals, and proportions to practical scenarios.

Language Skills

Ability to read, analyze, and interpret scientific and technical journals, financial reports, and legal documents; respond to customer and regulatory inquiries; write speeches and articles; present information to management and external audiences.

Physical Demands

Regular sitting and talking or hearing; use hands for handling or feeling; occasional standing and walking; lift up to 10 pounds.

Vision requirements: near, distance, color, peripheral, depth perception, focus.

Noise level generally moderate.

Working Hours

Exempt position requiring flexibility. Core hours Monday‑Friday 8:00 am – 5:00 pm. Nights, weekends, or holidays may be required.

Travel

Occasional domestic travel required.

• The Perks
• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401(k) with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus
• Equal Opportunity Employer

Male/Female/Disabilities/Veterans.

OSHA/ADA

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Disclaimer

The above statements are intended to describe the general nature and level of work performed by people assigned to this classification.

They are not intended to be an exhaustive list of all responsibilities, duties, and skills required.

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