Job Title: Medicare/Medicaid Fraud, Waste, and Abuse (FWA) Subject Matter Expert

Job Summary: We are seeking a knowledgeable and experienced Medicare/Medicaid Fraud, Waste, and Abuse (FWA) Specialist to join our team. The ideal candidate will serve as an expert in FWA and associated laws, regulations, and guidelines, providing guidance and support to ensure compliance and proactive measures for fraud prevention and detection within our organization. The role involves leading discussions, providing training, conducting risk assessments, developing policies and procedures, and collaborating with internal and external stakeholders to address FWA concerns effectively.

Responsibilities:

1. Serve as a subject matter expert (SME) in Medicare/Medicaid FWA, staying abreast of laws, regulations, and guidelines.
2. Apply expertise to support the organization's vision and strategic direction, infusing FWA protections into system operations.
3. Lead or actively participate in design meetings, providing FWA expertise to ensure compliance and effectiveness.
4. Provide guidance on resolving business needs and actively engage in all phases of the software development life cycle.
5. Conduct risk assessments and develop/implement policies, procedures, and controls to prevent and detect fraudulent activities.
6. Deliver expert guidance and training to project teams on investigative processes and best practices.
7. Support project teams with case management activities and oversee remediation efforts to prevent recurrence.
8. Coordinate with investigative resources and ensure compliance with relevant laws and regulations.
9. Collaborate with internal stakeholders, external partners, and regulatory agencies to address fraud-related concerns effectively.
10. Stay informed about emerging trends, technologies, and best practices in fraud prevention and detection.
11. Research, evaluate, and recommend new solutions to address regulatory requirements or enhance capabilities.
12. Analyze customer requirements and work with the technical team to meet customer needs effectively.

Additional Responsibilities (FWA SME):

• Ensure compliance with all relevant laws and guidelines to prevent and detect FWA within the UCM system.
• Influence the design of the UCM system to incorporate proactive measures for identifying potential FWA scenarios.

Qualifications:

• Bachelor's degree in a related field (e.g., Healthcare Administration, Legal Studies, Business) required; advanced degree preferred.
• Minimum of [X] years of experience in Medicare/Medicaid FWA, compliance, or related field.
• In-depth understanding of Medicare and Medicaid regulations, laws, and guidelines.
• Strong analytical skills with the ability to conduct risk assessments and develop effective policies and procedures.
• Excellent communication and interpersonal skills, with the ability to interact effectively with stakeholders at all levels.
• Proven ability to lead discussions, provide training, and collaborate with multidisciplinary teams.
• Experience with investigative processes and case management preferred.
• Knowledge of software development life cycle and its application in compliance-related initiatives.
• Ability to research, evaluate, and recommend new solutions to address regulatory requirements or enhance capabilities.
• U.S. residency requirement: Must have lived in the United States for at least three (3) out of the last five (5) years and able to pass background investigations.

Note: Participation in orals may be required for this position.

Equal Opportunity Employer: We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.