Fraud, Waste & Abuse Program Manager

Yamhill Community Care•McMinnville, OR

5d•Hybrid

About The Position

The Fraud, Waste & Abuse Program Manager is responsible for the design, implementation, and management of Yamhill Community Care’s (YCCO) Fraud, Waste, & Abuse (FWA) Program, providing expertise to staff in developing processes for tracking, investigating, and managing suspected FWA complaints.

Requirements

Excellent computer skills are needed, with a strong proficiency in Excel and similar tools and the ability to effectively manipulate and organize complex data.
Curious, detail-oriented, and inquisitive mindset.
Excellent organizational skills, including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy.
Ability to skillfully handle time-sensitive, challenging projects and complex case details.
Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix (cross-department) or shared resources across departments work model with a spirit of cooperation.
High degree of integrity and confidentiality required for handling information that is personal and confidential.
Strong written and verbal communication skills, including the ability to obtain information from others and deliver information in a concise, clear, and accurate manner.
The ability to navigate and understand claims data and various databases to identify and document suspected FWA.
Ability to communicate both professionally and effectively in all forms of communication.
Interpersonal skills, with the ability to listen, coach, and provide technical direction to others and to interact with tact and professionalism with all levels of the Organization and external contacts.
Ability to work in an environment with diverse individuals and groups.
Ability to remain flexible, positive, and adaptable.
Ability to work across the YCCO region and to work remotely, as needed.
Bachelor’s degree in relevant healthcare, investigations, or related discipline,
Minimum three (3) years of related work experience,
Minimum three (3) years of fraud, waste, and abuse experience,
Minimum four (4) years of experience in quality management and regulatory experience.
Certified in Healthcare Compliance (CHC).

Nice To Haves

Master’s degree
Credentialing and/or Medical Coding experience
Knowledge of Oregon’s Medicaid program
Experience completing delegation oversight assessments / audits.
Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI) credentials, or equivalent.

Responsibilities

Analyzes, reports, and monitors the FWA prevention efforts and provides recommendations to the YCCO Compliance Officer on matters related to FWA compliance.
Collaborates with the Compliance Officer on all referrals made to the Oregon Department of Justice Medicaid Fraud Control Unit (MFCU) and the Oregon Health Authority (OHA) Program Integrity Audit Unit (PIAU).
Oversees subcontractor activities to ensure compliance with the YCCO Compliance and Fraud, Waste, and Abuse Programs.
Develops and maintains a structure around a FWA and payment integrity program supported by policies, processes, procedures, workflows, and technology, in collaboration with the Compliance Officer and other applicable YCCO departments.
Manages Fraud, Waste & Abuse Program, including maintenance of annual YCCO FWA Plan, Assessment and Handbook-related policies in collaboration with the Compliance Officer.
At case intake, processes, prioritizes, analyzes, documents, tracks referrals and conducts background research, gathers supporting documentation, retrieves and reviews records, and coordinates with other individuals and departments, promptly.
Proactively performs records and data retrieval from Third Party Administrator (TPA) and providers, data mining, analysis, and research to identify potential opportunities to investigate suspected FWA to support of a full range of investigative functions from case development to referral in a timely manner.
Works closely with the YCCO Compliance Auditors on program integrity and FWA-related claims audits. Upon completion of such audit, presents report, including any overpayments made, to Compliance Officer.
Develop, translate, and execute strategies or functional / operational objectives for the company with regard to fraud, waste, and abuse.
Assist in the development and presentation of compliance and FWA training presentations.
Serve as primary point of contact for external oversight agencies to include the OHA Office of Program Integrity and Department of Justice Medicaid Fraud Control Unit.
Serve as a member of the YCCO Compliance Committee and report-out on FWA matters.
Manage and oversee the preparation and submission of FWA regulatory reporting requirements to OHA, including quarterly and annual reports and annual FWA deliverables.
Develops and maintains / updates FWA-related policies and procedures.
Performs matrixed work with other YCCO departments as needed, including Health Plan Operations and Finance.
Regularly attend fraud-related meetings with OHA.
Takes a matrixed approach to all duties and works in partnership with other YCCO Departments to achieve YCCO’s mission.
Communicates updates on assignments to supervisors, managers, and other departments and committees.
Leads in the preparation and delivery of written documents and oral briefings and presentations on potential FWA cases and other related activities.
Assists with the development and implementation of initiatives and the completion of regulatory planning and reporting requirements.
Engages in outreach with internal and external partners, regulators, and vendors, to ensure the completion of assignments.
Supports legal proceedings as necessary, including law enforcement subpoenas, data requests, and preparation for civil or criminal actions related to suspected FWA.
Responsible for delegation oversight specific to FWA, including subcontractor FWA monitoring and training, and reports findings and successes to the Compliance Officer.
Works with other departments to compile, review, and submit annual External Quality Review (EQR), including onsite activities, when relevant.
Assists Compliance Department staff with continuous process improvement around program integrity, FWA, and EQR.
Assists the Compliance Officer and Compliance Auditors on the development and implementation of an annual plan to perform program integrity audits of providers and subcontractors to assist YCCO to validate accuracy of encounter data validation against provider charts.
Coordinates with YCCO’s Finance Department on overpayments and related reporting.
Collaborates with department staff with deliverable timelines and submission.
Develops and implements tracking tools to ensure timely issue resolution and compliance with all applicable standards specific to FWA.
Collaborate with YCCO’s Compliance Officer and auditors on the development of the annual audit work plan which includes the annual FWA audit and monitoring work.
Serves as functional backup for Compliance Officer and serve as point of contact for Compliance Department if / when needed.
Respectfully takes direction from Supervisor.
Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.
Participates in the preparation and submission of regulatory and contract required deliverables.
Works closely with other YCCO departments, including Health Plan Operations, to assist with audits; including the External Quality Review (EQR), as needed.
Proposes and implements process improvements.
Meets deadlines for completion of assigned responsibilities and projects.
Maintains agreed upon work schedule with punctual, regular, and predictable attendance.
Attends in person Annual Company Conference in Oregon; typically held in the fourth week of September.
Demonstrates cooperation and teamwork using a professional and respectful demeanor.
Provides cross-training on specific job responsibilities.
Meets identified goals that contribute to departmental goals.
Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation.
Respectfully takes direction from Supervisor.
Performs other duties as assigned.