Project Manager - Healthcare Fraud , Waste & Abuse
12 days ago
West Palm Beach
Job Description Job Description Company: Palm Beach Accountable Care Organization Job Title: Project Manager – Fraud, Waste, and Abuse Department: Performance Improvement Team Reports To: Director of Performance Improvement FLSA Status: Exempt Prepared Date: 9/5/2025 DISCLAIMER: Job descriptions are not meant to be all-inclusive and/or the job itself is subject to change. Nothing in this job description restricts management's right to assign or reassign duties. SUMMARY: As a Project Manager – Fraud, Waste, and Abuse you will be responsible for leading PBACO’s fraud prevention initiatives across all payer programs. This includes analyzing claims data, identifying suspicious providers and companies, coordinating attestation collection with practices, preparing and submitting fraud reports to enforcement agencies, and continuously improving processes for early detection of fraudulent schemes. This role requires a combination of project management, data analysis, provider engagement, and compliance oversight to protect patients, reverse fraudulent charges, and preserve ACO financial integrity. Essential Duties and Responsibilities: Fraud Identification & Reporting • Review Medicare and commercial claims data to identify fraudulent DME, wound care, genetic testing, and other high-risk claims., • Report suspected fraud cases to OIG and Safeguard Services in compliance with established protocols., • Maintain thorough documentation of all identified fraud, submissions, and enforcement communications., • Review paid claims across a rolling three-year period to identify suspicious patterns., • Flag claims based on defined risk criteria (e.g., paid amounts, high-volume CPT codes, no evidence of ordering provider visit)., • Prepare claim-level attestation documents for distribution to practices via Super DocACO app., • Coordinate with Provider Consultants to secure verbal and written attestations from practices., • Track and update attestation logs, escalating nonresponsive practices when needed., • Submit fraudulent companies for enforcement once threshold criteria are met (≥7 verbal attestations)., • Bundle multiple fraudulent companies into monthly submission packages for OIG and Safeguard Services., • Develop new workflows for emerging fraud schemes (e.g., wound care billing evolving into fraud)., • Enhance detection efficiency through automation, SQL, and technology tools., • Design and implement cross-functional initiatives to optimize processes and improve efficiency., • Support company philosophies, objectives, decisions, and policies., • Perform other duties as assigned within the scope of responsibilities and goals of the performance improvement department., • Ensure adherence to HIPAA, confidentiality, and organizational privacy standards., • Provide Board of Managing Member’s Meeting updates on fraud, waste, and abuse projects upon request by leadership. Key Performance Indicators (KPIs) Fraud Identification & Analysis • ≥95% of new DME claims reviewed within 10 business days of data load., • Minimum one submission package to OIG and Safeguard Services monthly, including all companies meeting attestation thresholds., • 100% of submissions documented and confirmed with enforcement agencies., • A minimum of 7 or all verbal attestations per identified fraudulent company secured within 45 days of request., • ≥30% of written attestations secured within 90 days of request., • ≥90% of practice communications acknowledged within 14 business days., • HIPAA Compliance: Maintain 100% adherence to HIPAA and organizational privacy standards. Competencies: To perform the job successfully, an individual should demonstrate the following competencies: • Analytical and advanced problem-solving strategies., • Minimum level computer skills in a Microsoft Office environment: Medium, • Knowledge of Excel, Word, and Power Point Presentations in a business setting., • Strong internet research capabilities., • High attention to detail., • Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions., • Safety and Security - Uses equipment and materials properly., • Attendance/Punctuality - Is consistently at work and on time., • Knowledge of legal and ethical consideration related to patient information., • Proven people skills with the ability to interface effectively both internally and externally with a wide range of people including physicians, office staff, hospital executives, medical groups, IPA’s, community organizations and other health plan staff., • Knowledge of and experience collaborating with Provider Communities., • Experience with Electronic Medical Record (EMRs) or Health Information Management (HIMs) systems., • An elevated level of engagement and emotional intelligence, • Progressive operational experience within a medical center, clinical group, or hospital setting., • Basic knowledge of Population Health Strategy, • Proven ability to function effectively in matrix management environment and as a member of an interdisciplinary team. Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education and/or Experience: Required: Bachelor’s degree in Healthcare Administration, Compliance, Data Analytics, or related field. 3+ years of experience in healthcare compliance, fraud prevention, program integrity, or project management. Familiarity with Medicare regulations, CMS fraud guidance, and enforcement agencies (OIG, UPIC). Preferred: Experience in an Accountable Care Organization (ACO), payer, or compliance role. Knowledge of medical coding (CPT/HCPCS), DME claims processes, and fraud detection tools. Language Skills: Ability to read and comprehend simple instructions, correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one situations to visitors, clients, and other employees of the organization. Reasoning Ability: Ability to think critically, objectively and unbiased. Quickly learn/adapt to healthcare industry standards, codes, data, and business practices. Computer Skills: MS Office Productivity Tools (Word, Excel, Outlook, PowerPoint), Internet, SQL & Data Objects, various report writing tools. Programming skills preferred. Other Skills and Abilities: High accuracy and extreme confidentiality is a MUST. Highly meticulous and must possess a remarkably high degree of organization. Physical Demands: While performing the duties of this Job, the employee will have a combination of standing, sitting, bending, and reaching. May work at computer monitors for prolonged periods. The employee may lift and/or move up to ten pounds.