Claims Program Manager- FWA

Jan 12 2021
Full Time

A bit about us: 

We’re on a mission to change healthcare — how it’s paid for, delivered, experienced. We want to put people center stage, not process or profit. We are guided by a deep belief that every person on Medicare should be treated like we would treat a member of our own family: with loving care and a profound commitment to their health and well-being. 

That’s why we’re gathering a whole bunch of smart, big-hearted people to create a new kind of healthcare company — one that combines compassion, health insurance, clinical care, and technology seamlessly. 

We want to throw the long ball with people we love for a cause we believe in. Life is short. Join us.

Devoted Health is a new health care company looking to improve the lives of seniors in America. We are guided by a deep belief that every senior should be treated like we would treat a member of our own family: with loving care and a profound commitment to their health and well-being.  With aging demographics and rising health costs, this is an industry and problem space that needs today’s best talent working on solutions with high integrity and a long term view. We will improve the lives of seniors by helping them navigate the healthcare system, by utilizing world-class technology and data to enable a simplified experience, by partnering with top providers for better health outcomes. 

Make a difference... a big difference. You will have the opportunity, in a unique and dynamic culture, to be a part of something incredibly meaningful. We’re a disruptive startup with an inspiring mission. Learn and grow alongside our world-class team of healthcare, technology, and data leaders, dedicated to building a health plan and clinical services that care for everyone like they were our own mothers or fathers. Our team and board members have decades of experience in health care entrepreneurship, data, technology, services, and policy. With their support, we look forward to building a health plan and clinical services that will give seniors easy access to the high-quality care they deserve.

At Devoted, we know that one of the most important ways we will build trust is by ensuring we pay claims accurately and on time. We also have a fiduciary responsibility to protect the Medicare Fund and this role will play an integral part in doing that. The Fraud Waste and Abuse (FWA) Claims Program Manager will be primarily responsible for the design, implementation, and management of the company's FWA Program specific to medical and pharmacy claims. Providing expertise to the organization in developing processes for tracking, investigating, and managing suspected FWA complaints. The role will analyze, report and monitor the FWA prevention efforts and provide recommendations to leadership on matters related to FWA compliance. The program manager will track and report company activities to ensure compliance with state and federal FWA requirements.

Responsibilities will include:

  • Responsible for oversight, management, development, implementation, and communication of the FWA program.
  • Oversight of the FWA vendor which is the primary driver of FWA programs
  • Develop the annual work plan which will outline and detail the annual FWA monitoring plan.
  • Independently researches FWA issues and effectively employ investigative resources/techniques.
  • Maximize the recoveries and avoidance for claims payments with a demonstrated ability to achieve results.
  • Work to develop prospective and retrospective fraud and abuse detection, investigation, recovery and avoidance programs in conjunction with the vendor
  • Responsible for notification of MEDIC and other state and federal agencies of potential fraud activities.
  • Assist in the development and presentation of FWA training presentations.
  • Responsible for creating and presenting FWA reports to Senior leaders 
  • Manage and oversee the preparation and submission of FWA regulatory reporting requirements to CMS and other agencies. 
  • 10% travel 

Attributes to success:

  • Ability to work in a start-up, fast-paced environment
  • Curiosity to recognize process deficiencies, recommend improvements and implement solutions. You are passionate about process improvement and efficiency, and have an ability to predict and prevent bottlenecks
  • Flexibility and willingness to change according to business needs
  • Ability to motivate staff at all levels 
  • A true operator who will roll up your sleeves and do whatever it takes to get the job done
  • You have a bias towards action and execution, and a track record to support your ability to get things done
  • Clear head for process and technology
  • You have stamina for tackling hard problems
  • Experience working with complex data and implementing systems and workflows
  • A creative thinker with a can-do attitude 
  • Strong communicator who can work with cross-functional stakeholders and drive alignment

Desired skills and experience:

  • 5+ years in fraud, waste, and abuse investigations
  • 3-4 years experience with Medicare and/or Medicaid Programs
  • Bachelor’s degree in business, management, health care administration or other related field or equivalent work experience required. 
  • Fraud examiner certification a plus 
  • Experience with data analysis techniques
  • Track record of success developing and implementing systems and processes and setting and achieving ambitious targets
If you love running towards complex challenges and transforming them into solutions, if you want to make a potentially huge impact on many lives, and if you are looking for a disruptive startup with an inspiring and talented team, Devoted Health may be the place for you! 

Devoted is an equal opportunity employer.  We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
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