Yamhill Community Care · 3 weeks ago
Fraud, Waste & Abuse Program Manager
McMinnville, OR
Full-time
Hybrid
Mid, Senior Level
3+ years expYamhill Community Care is a nonprofit coordinated care organization dedicated to managing healthcare for Medicaid members in Yamhill County. The Fraud, Waste & Abuse Program Manager is responsible for designing, implementing, and managing the FWA Program, providing expertise to staff in tracking, investigating, and managing suspected fraud, waste, and abuse complaints.
CommunitiesHealth CareNon Profit
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
Qualification
Required
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)
OR: Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI) credentials, or equivalent
Preferred
Master's degree
Credentialing and/or Medical Coding experience
Knowledge of Oregon's Medicaid program
Experience completing delegation oversight assessments / audits
Company
Yamhill Community Care
Yamhill Community Care (YCCO) is a Coordinated Care Organization (CCO) that serves Oregon Health Plan (OHP) members in Yamhill County, and parts of Washington and Polk counties.
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Seamus McCarthy
President and Chief Executive Officer
Company data provided by crunchbase