Program Manager, Fraud, Waste and Abuse

Gainwell Technologies

. Lead Fraud, Waste & Abuse (FWA) and Program Integrity initiatives from strategy through implementation, ensuring regulatory compliance and operational excellence .

Posted 9/21/2026full-timeRemote • United StatesSeniorLead💰 $96,500 - $137,900 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in leading Fraud, Waste & Abuse initiatives and ensuring compliance within healthcare programs. Proficient in data analysis, process optimization, and cross-functional collaboration to enhance program integrity and operational effectiveness.

Highest-signal resume keywords

Fraud, Waste & Abuse ManagementHealthcare Program IntegrityData Analysis and ReportingCross-Functional LeadershipRegulatory Compliance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AnalyticsProcess DesignUser Acceptance TestingAudit MethodologiesInvestigative PracticesOverpayment IdentificationPolicy DevelopmentQuality AssuranceExecutive-Level ReportingProject Management

Soft Skills

Analytical ThinkingCritical ThinkingFacilitation SkillsWritten CommunicationPresentation Skills

Tools & Technologies

Data Visualization PlatformsAudit Management SoftwareCase Management ToolsRequirements Management Tools

Certifications & Qualifications

Certified Fraud ExaminerAccredited Health Care Fraud InvestigatorCertified in Healthcare ComplianceCertified Internal AuditorProject Management Professional

Industry Keywords

Medicare RequirementsMedicaid RequirementsHealthcare ClaimsPayment IntegrityManaged CarePharmacy Benefit ManagementGovernment Healthcare Programs

Tech Stack

Tools & technologies

PMP

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

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
Experience leading complex, cross-functional implementations from requirements and design through testing, deployment, and operational transition
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

Benefits

Comp & perks

Work flexibility
Learning and career development
Technical credentials and certifications
Generous, flexible vacation policy
Educational assistance
Leadership and technical development academies
401(k) employer match
Comprehensive health benefits
Opportunities to travel through your work (0-25%)