MedImpact Healthcare Systems, Inc. · 14 hours ago
Fraud, Waste, and Abuse Investigations Manager
San Diego, CA
Full-time
Hybrid
Mid, Senior Level
$85K/yr - $145K/yr
7+ years expMedImpact Healthcare Systems, Inc. is looking for extraordinary people to join their team as a Fraud, Waste, and Abuse Investigations Manager. This role involves overseeing operational activities related to Pharmacy Compliance and conducting comprehensive investigations to improve surveillance of fraud, waste, and abuse in the healthcare sector.
Health CarePharmaceutical
No H1B
Responsibilities
Responsible for fraud and abuse detection activities for the TennCare PBA Programs, including the Fraud and Abuse Compliance Plan. Will be responsible for day-to-day Provider investigation-related inquiries
Utilizes prescription and medical claim data to generate clinical recommendations according to 'Global' Drug Utilization Review program protocols. Provides clinical recommendations pertaining to, but not limited to, gaps in care, high risk medications, compliance and adherence, drug interactions, therapeutic substitution, and generic substitution. Utilizes client formulary information to guide appropriate medication recommendations. Keep current with new and emerging clinical trends. Provides active participation in departmental meetings to improve clinical programs and enhance processes. Share clinical information and department procedure protocols during client site visits. Assists the FWA Team with new clinical programs and system enhancements. Follow all policies and procedures related to job clinical support as needed for special projects and other duties as assigned by the Director, Compliance, FWA. Perform other duties as assigned to meet departmental objectives
Under the guidance of the FWA Management, this position is responsible for the accurate and thorough clinical investigation of potential external fraud and abuse involving commercial and government lines of business. The scope of accountability includes investigating and remediating allegations of fraud, waste and abuse involving providers. Primary activities include substantiating referrals, case research and planning, conducting onsite or desk audits, clinical reviews of medical records to ensure correct billing of services and appropriateness of care, interviewing potential witnesses, developing corrective action plans, developing correspondence to impacted parties, managing disputes and collaborating with law enforcement and regulatory agencies. Additional accountability includes cooperation of fraud, waste and abuse efforts with external business partners
Reviews medical and pharmacy records, researches and investigates complex cases for the purpose of detecting fraud both internal and external involving submission/payment of claims and identifies FWA issues for follow-up. The FWA Investigation Manager interprets a variety of documents including, but not limited to client contracts, group benefit structures, Workplan Policies and Procedures, governmental policies as well as diverse regulatory and legal requirements
In conjunction with the FWA Clinical Pharmacist, thoroughly researches an allegation or issue and develops sources of information to create a plan of action, accumulating sufficient detailed evidence including statements, documents, records, exhibits, and photographs for the successful adjudication of identified FWA cases or audit results
Makes sound rational clinical judgments and decisions in the progression of their cases, keeping management routinely apprised of the progress
Requests and analyzes data in order to identify fraudulent billing patterns
Solves problems using sound professional judgment to determine the appropriate course of action and independently follows through, when necessary
Provides routine interaction, referrals, and coordination with Medicaid, CMS, NICB, MEDIC, local, state and federal law enforcement, and regulatory licensing boards
Monitors the regulatory interactions with our network of providers, prescribers, and members
Functions independently with appropriate oversight in sensitive situations
Evaluates situations accurately and interacts frequently with managers, supervisors, and legal to ensure complex issues are addressed appropriately
Prepares comprehensive Reports of Findings and prepares cases for potential prosecution and civil settlement by documenting findings in a clear and concise manner
May be required to review files and testify in court or the Credentialing Adjudication Committee, as needed, in matters regarding litigation/adjudication related to their reviews
Manages cases as assigned, prioritizing case load as appropriate. Maintains case logs, prepares records and regular status reports
Interacts frequently with providers of health care, often under adverse conditions due to potential discovery of fraud, waste or abuse. The incumbent shall discuss sensitive material in a professional, fair and accurate manner
Acts as primary point of contact with law enforcement for assigned cases in conjunction with the FWA Investigator
Interprets various data analyses and information gathered in the detection process, determines what information to analyze further and what trends or issues to report to others
Prepares recommendations on preventive/corrective measures for the deterrent of future fraud
Supports other FWA personnel and analysts with their cases by providing medical information/expertise and as necessary, performs clinical reviews of medical records for other FWA cases
Contributes to development of medical procedural guidelines, protocols, and employee training. The incumbent shall remain knowledgeable about State and Federal laws involving health care fraud
Consistently demonstrates high standards of integrity by supporting the Medlmpact's Mission and Values and adhering to the Corporate Code of Conduct
Maintains high regard for member privacy in accordance with the corporate and regulatory privacy rules, regulations, policies and procedures
Interfaces appropriately with many different provider types, attorneys, external agencies, other departments
Discerns when to suggest deviations from standard practices based on tangible and intangible factors
Offers process improvement suggestions and participates in the solutions of more complex issues/activities
Mentors staff and assists with training and coaching, whenever necessary
Serves as a subject matter expert and liaison, representing non-clinical staff in discussions with clients or other departments
Serves as an internal auditor/peer reviewer for new investigative staff, as needed
Provides back up for Supervisor/Manager, whenever necessary
Provides day-to-day oversight of department, including developing and administering policies, business processes and quality standards, and assist in developing and managing a departmental policies and procedures
Establishes procedures to ensure compliance with state and federal FWA and FWA contracts and agreements
Ensures that deliverables meet the quality levels expected by internal departments and external clients
Responsible for assisting in coordinating all contracting efforts with outside vendors that support provider audits, credentialing and FWA
Responsible for defining standards in support of the department-wide goals, to ensure consistent execution of all related projects by multiple teams, including: planning, execution, effectiveness, standards, escalations, and how to manage unique investigations
Oversee operations between the BA/IT, Pharmacy Compliance, FWA and FIST to ensure projects are delivered on schedule and meet state and/or federal regulations
Qualification
Required
BS/BA and 7+ years' experience or equivalent combination of education and experience, and 4 years' of SME in respective areas
Strong proficiency with personal computers and MS Office products to include intermediate to advanced working knowledge of MS; Word, Excel, Access and Outlook
Familiarity with relational database systems required
Knowledge of SQL software front ends such as MedOptimize required
Strong aptitude to learn and adapt to new programs
Continuous improvement of and training in data mining skills
Good working knowledge of research development, methodologies, reporting, analysis, and publishing
Ability to balance a high volume of work & variety of tasks and prioritize urgent issues
Detail oriented with a high degree of accuracy and time management
Strong passion for providing service to the customer as defined as our clients, members, and other departments
Self-starter with the ability to work independently and as part of our team
Ability to influence others, lead workgroups, and coordinate service requests throughout the organization
Ability to gather, document, and communicate business requirements and client specifications
Ability to understand and interpret contract language and negotiate favorable contract terms
Deep knowledge of the health benefits arena, preferably in pharmacy benefits management, Medicare Part D, Medicaid and Health Exchanges
Superior ability to determine State and Federal fraudulent activity and compile necessary documentation for prosecution presentation
Explain and interpret these findings to law enforcement authorities in a cognizant manner
Must remain current and cognizant of medical and pharmacy standards of care and practices in the community
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations
Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents
Ability to write speeches and articles for publication that conform to prescribed style and format
Benefits
Medical / Dental / Vision / Wellness Programs
Paid Time Off / Company Paid Holidays
Incentive Compensation
401K with Company match
Life and Disability Insurance
Tuition Reimbursement
Employee Referral Bonus
Company
MedImpact Healthcare Systems, Inc.
MedImpact is the nation’s largest independent health solutions and pharmacy benefit company, serving commercial health plans, government programs, self insured/employer groups, and millions of consumers.
1001-5000 employees
Funding
Current Stage
Late StageTotal Funding
$1.38M2013-09-19Seed· $1.38M
Leadership Team
Frank Bunton
VP, CISO (Chief Information Security Officer)
Larry Biggs
Manager, Information Security
Recent News
Pharmacy Benefit Management Institute®
2025-09-26
2025-09-12
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