Payment Integrity and Fraud, Waste and Abuse Team Lead

PacificSource Health Plans • WFH: VA, VA

4d • $83,310 - $145,793 • Onsite

About The Position

The Payment Integrity and Fraud, Waste and Abuse (FWA) Team Lead is responsible for overseeing the daily operations of PacificSource’s Payment Integrity and FWA programs. This role provides leadership for Payment Integrity and FWA activities while supporting the development and execution of pre-payment and post-payment initiatives designed to ensure payment accuracy, regulatory compliance, and responsible stewardship of healthcare resources. The Team Lead serves as a subject matter expert in payment integrity operations, fraud prevention, audit activities, provider recoveries, and regulatory requirements. This position works closely with Claims, Compliance, Finance, Provider Relations, and external vendors to identify opportunities for cost avoidance, overpayment recovery, process improvement, and program effectiveness.

Requirements

• Minimum of 4 years of senior-level healthcare operations, payment integrity, fraud prevention, claims auditing, claims administration, or related experience required.
• Knowledge of healthcare claims processing, reimbursement methodologies, coding systems, and payment integrity concepts.
• Knowledge of fraud, waste, and abuse regulations and investigative practices.
• Understanding of Medicare, Medicaid, and commercial health plan regulatory requirements.
• Knowledge of ICD-10, CPT, HCPCS, DRG, and related reimbursement methodologies.
• Strong analytical, problem-solving, and decision-making skills.
• Ability to interpret data, identify trends, and develop operational recommendations.
• Ability to communicate effectively with leadership, regulators, providers, vendors, and cross-functional business partners.
• Accountable leadership
• Collaboration
• Communication (written/verbal)
• Critical thinking
• Decision-making
• Influencing
• Listening (active)
• Organizational skills/Planning and Organization

Nice To Haves

• Prior supervisory experience preferred.

Responsibilities

• Provide direct supervision, coaching, performance management, and professional development for assigned Payment Integrity and FWA staff.
• Supervise and direct payment integrity claims adjustment activities, ensuring timely and accurate implementation of claim corrections, recoveries, and financial adjustments.
• Oversee recovery inventory management and ensure identified overpayments, audit findings, and recovery opportunities are appropriately processed, tracked, and resolved.
• Coordinate daily work activities, workload prioritization, inventory management, and resource allocation across payment integrity functions.
• Support the execution and on-going operations of pre-payment and post-payment payment integrity programs, including audits, claims reviews, recoveries, and fraud prevention activities.
• Oversee the investigation, tracking, documentation, and resolution of potential fraud, waste, and abuse referrals and cases.
• Monitor payment integrity performance metrics and recovery results and prepare reports for leadership, compliance committees, and regulatory agencies as needed.
• Implement and maintain payment integrity policies, procedures, workflows, and operational controls.
• Ensure compliance with applicable federal and state regulations, CMS requirements, contractual obligations, and internal policies.
• Serve as a primary operational liaison between Payment Integrity, Compliance, Claims Operations, Provider Relations, Finance, and Special Investigations functions.
• Coordinate day to day operational activities with external vendors supporting audit, recovery, analytics, and fraud detection programs and monitor adherence to established service levels.
• Review audit findings, recovery opportunities, and investigative outcomes to ensure consistency, accuracy, and adherence to established standards.
• Support preparation and submission of regulatory reporting requirements related to fraud, waste, abuse, and payment integrity activities.
• Participate in internal and external audits and assist with corrective action planning and implementation.
• Identifying emerging risks, payment vulnerabilities, billing trends, and opportunities for program improvement and escalate recommendations to leadership.
• Lead or participate in departmental projects, process improvement initiatives, and cross-functional workgroups.
• Actively participate as a key member of management and leadership meetings.
• Represent Payment Integrity on internal committees and workgroups as assigned.
• Coordinate business activities by maintaining collaborative partnerships with key departments.
• Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees.
• Actively participate as a key team member in department meetings.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
• Participate in compliance and operational initiatives as needed.
• Assist with training and education efforts related to payment integrity and FWA prevention.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Benefits

• Our Values

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree