Program Manager Fraud, Waste and Abuse (FWA)

Summary

The Principal, FWA Program Management provides senior-level leadership for the design, implementation, and continuous improvement of healthcare fraud, waste, and abuse programs. This role translates regulatory, contractual, operational, and business requirements into practical program documentation and workflows; leads implementation readiness and user acceptance testing; identifies emerging audit and investigative trends; and supports desk and field audits. The Principal serves as a subject-matter expert and trusted advisor across program integrity, pharmacy operations, analytics, compliance, legal, product, technology, and client teams.

Your role in our mission

• Lead Fraud, Waste & Abuse (FWA) and Program Integrity initiatives from strategy through implementation, ensuring regulatory compliance and operational excellence.
• Drive cross-functional collaboration to design, deploy, and optimize processes, systems, controls, and governance frameworks.
• Analyze claims, provider, member, and audit data to identify fraud trends, billing anomalies, financial risks, and recovery opportunities.
• Partner with analytics teams to develop detection strategies, business rules, dashboards, and investigative workflows.
• Oversee testing, quality assurance, and user acceptance activities to ensure solutions meet business and compliance requirements.
• Support audits and investigations through data analysis, documentation review, evidence gathering, and actionable recommendations.
• Identify operational risks and process improvement opportunities to strengthen program effectiveness and outcomes.
• Prepare executive-level reports and insights on program performance, audit findings, investigation results, and emerging risks.
• Provide leadership, mentorship, and subject matter expertise to analysts, auditors, investigators, and implementation teams.
• Serve as a trusted partner to clients, regulators, vendors, and internal stakeholders, driving accountability and continuous improvement.

What we're looking for

• Bachelor’s degree in healthcare administration, pharmacy, nursing, business, public administration, criminal justice, information systems, analytics, or a related field; equivalent relevant experience may be considered.
• Eight or more years of progressively responsible experience in healthcare program management, program integrity, FWA, payment integrity, special investigations, compliance, auditing, claims operations, or a related discipline.
• Demonstrated experience leading complex, cross-functional implementations from requirements and design through testing, deployment, and operational transition.
• Hands-on experience developing policies, procedures, process designs, test cases, user acceptance testing materials, audit workpapers, and executive-level reporting.
• Working knowledge of healthcare claims, provider billing, audit methodologies, investigative practices, evidence documentation, and overpayment identification.
• Knowledge of applicable federal and state healthcare program integrity requirements, including Medicare and/or Medicaid requirements.
• Strong analytical, critical-thinking, facilitation, project leadership, written communication, and presentation skills.
• Ability to manage multiple priorities, exercise sound judgment, protect confidential information, and work effectively with technical and nontechnical stakeholders.
• Ability to travel for field audits, client meetings, or implementation activities as business needs require.
• Experience supporting Medicaid, Medicare, managed care, pharmacy benefit management, or government healthcare programs.
• Experience with claims analytics, data visualization, audit or case-management platforms, and structured defect or requirements-management tools.
• Professional certification such as Certified Fraud Examiner, Accredited Health Care Fraud Investigator, Certified in Healthcare Compliance, Certified Internal Auditor, Project Management Professional, or an equivalent credential.

What you should expect in this role

• Remote-based opportunity within the United States
• Opportunities to travel through your work (0-25%)
• Video cameras must be used during all interviews, as well as during the initial week of orientation
• The deadline to submit applications for this posting is 9/30/2026