Manager - Fraud Waste and Abuse Special Investigations

Worldwide Insurance Services•King of Prussia, PA

1d•Hybrid

About The Position

The Manager- Fraud, Waste and Abuse Special Investigations leads the organization’s efforts to detect, investigate and prevent fraud, waste and abuse across international healthcare claims. This role is responsible for overseeing the end-to-end investigative function, guiding a team of investigators, and ensuring consistent, high-quality case management. The Manager drives strategic priorities, strengthens cross-functional partnerships and enhances investigative capabilities to reduce financial loss, mitigate risk and support regulatory compliance globally.

Requirements

5+ years of insurance industry or other relevant experience required.
College degree or equivalent experience.
Strong working knowledge of international health insurance claims.
Knowledge of US Domestic health insurance claims is a plus.
Prior experience identifying or investigating fraud, waste, and abuse is highly valued.
Multi-lingual strongly preferred.
Strong attention to detail and problem-solving skills.
Excellent written and verbal communication skills.
Demonstrated ability to build relationships and negotiate positive outcomes.
Prior experience leading high performing teams in a fast-paced environment strongly preferred.
Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
Ability to deal with ambiguity and drive for resolution.
Willingness and ability to learn and apply new skills.
Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

Nice To Haves

Knowledge of US Domestic health insurance claims is a plus.
Prior experience identifying or investigating fraud, waste, and abuse is highly valued.
Multi-lingual strongly preferred.
Prior experience leading high performing teams in a fast-paced environment strongly preferred.

Responsibilities

Oversee complex fraud investigations, including reviewing case strategies, findings and final reports.
Lead a team of individuals responsible for detecting and investigating fraud in healthcare claims from around the world.
Optimize performance with attention to savings realization, inventory management, process design and documentation, KPI development, and reporting.
Identify opportunities or gaps in current processes and implement solutions to improve team performance and customer experience.
Cultivate relationships with key business partners and relevant law enforcement agencies.
Coordinate activities across departments (ex. FWA, Clinical, Legal, Customer Service, Claims) and external entities (ex. home plans or vendors).
Develop capacity models and business cases to ensure support for growth.
Deploy resources effectively between pre-payment prevention and post payment recovery capabilities.
Increase awareness and training related to identifying and preventing fraud within the FWA team and the broader organization.
Ensure timely resolution and notification of escalated cases.
Track activity and produce reports to measure impact and document actions.
Support cross-functional projects and initiatives as a subject matter expert as needed.
Support commercial teams in client meetings and finalist presentations as needed.
Contact external 3rd parties through outbound call or email to obtain additional information or verify claim information.
Validate accuracy of claim charges and initial processing decisions.
Perform online research to fill in gaps in existing tools and understanding.