DOCTORS HEALTHCARE PLANS, INC.
Manager, Fraud, Waste & Abuse (FWA)
DOCTORS HEALTHCARE PLANS, INC., Miami, Florida, us, 33222
Fraud, Waste & Abuse Manager
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 systems, 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 requirements 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.
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 systems, 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 requirements 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.