Fraud, Waste and Abuse Subject Matter Expert Manager

Clearance Level
None
Category
Data Analysis
Location
Remote, Based in USA

REQ#: RQ103597

Travel Required: Less than 10%
Public Trust: None
Requisition Type: Regular

At GDIT, people are our differentiator. Our work depends on a Fraud, Waste and Abuse Subject Matter Expert (FWA SME) Manager joining our team to support Centers for Medicare and Medicaid Services anti-fraud activities. As a FWA SME Manager supporting the Healthcare Fraud Prevention Partnership, you will direct the activities of a team of FWA SMEs, collaborating with Data Scientists and Business Intelligence Developers to guide fraud detection strategies and communicate outcomes to a large partnership of public and private healthcare payers. Your FWA SME team will be a part of a 15-person team supporting the Trusted Third Party fraud, waste and abuse data analytics.

We are GDIT. The people supporting and securing some of the most complex government, defense, and intelligence projects across the country. We ensure today is safe and tomorrow is smarter. Our work has meaning and impact on the world around us, but also on us, and that’s important.

GDIT is your place. You make it your own by embracing autonomy, seizing opportunity, and being trusted to deliver your best every day.

We think. We act. We deliver. There is no challenge we can’t turn into opportunity.

In this role, a typical day will include:

  • This position manages a team of FWA Subject Matter Experts, embedded within a multi-disciplinary organization of Data Scientists, Business Intelligence Analysts and FWA Subject Matter Experts. Our team is 100% remote and distributed throughout the country.

  • This position will be responsible for planning, directing and overseeing the development of FWA models and algorithms in multi-payer environment, advising data science staff on clinical, policy and billing aspects of FWA study design.

  • The FWA SME Manager will facilitate the FWA SME team’s collaboration with Data Scientists, Business Intelligence Developers, and clients, to develop meaningful analyses for FWA modeling results and provide policy and research support to the analytic team.

  • This FWA SME Manager will be responsible for overseeing the development of analytic design documents, involving policy, program, and industry research, and will synthesize research findings into cogent analytic rationale that can be articulated to end users;

  • The FWA SME Manager oversees quality review on analytic designs and outputs to ensure consistency with protocol and adequacy to meet methodological objectives, and to ensure compliance with applicable access standards.

  • The FWA SME Manager will help to craft and deliver outstanding presentations to clients, stakeholders, and HFPP Partners, and effectively communicate the key insights and value propositions of the TTP analytic outputs.

  • This FWA SME Manager will be called upon to direct the FWA SME team to identify actionable findings within the analytic output across the several dozen HFPP Partners; the position likewise involves packaging and communicating those value propositions to the various enforcement arms within the healthcare fraud partnership, including private payers SIUs, government administrative agencies such as CMS and Medicaid programs, and Law Enforcement.

  • This team member will manage a team of 4-6 FWA SMEs.

REQUIRED QUALIFICATIONS

  • Registered Nurse (RN), Bachelor of Science in Nursing (BSN), Licensed Practical Nurse (LPN) or similar caliber clinical training and experience.

  • Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC) or Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA)

  • 15+ years of relevant experience in healthcare.

  • 10+ years of relevant experience in healthcare fraud investigations, with demonstrable experience across the spectrum of fraud detection within two or more of the following program types: Medicare, Medicaid, Private Insurance

  • 10+ years of experience utilizing medical claims coding systems (e.g., ICD-10, CPT, HCPCS, NDC)

  • Strong knowledge of health care benefit structure and claim processing systems

  • Experience researching and interpreting payer medical (coverage) policies (e.g., LCDs, NCDs, private carrier medical policies) and common industry claim edits (e.g., NCCI)

  • Prior experience managing multi-person SME or Medical Review teams with a focus on healthcare data; strong supervisory experience leading project teams and/or mentorship ability guiding new team member.

  • Demonstrated expertise in the complete Microsoft Office Suite including: Word, Excel, and PowerPoint (candidate may be called upon to show examples from portfolio or submit practicum assignments).

DESIRED QUALIFICATIONS

  • Deep experience in CMS/CPI fraud, waste and abuse contracts.

  • Knowledge of data analysis techniques for fraud, waste and abuse detection, and documentation of those models.

  • Ability to communicate technical and non-technical language to technical and non-technical audiences

  • Ability to prioritize multiple tasks to meet established deadlines and satisfy internal and external customer demands

  • Proficient in using Tableau Reader as an end-user

  • Ability to compile and deliver public presentations when necessary

WHAT GDIT CAN OFFER YOU

  • The GDIT HFPP Trusted Third Party is the only data warehouse of its type anywhere, bringing in many billions of healthcare claims from dozens of healthcare payers, including federal, state and local plans both public and private. We use this data warehouse solely for fraud, waste and abuse analytics.

  • The TTP is responsible for identifying overpayments, fraud leads, and meaningful insights about abusive billing behaviors through a cross-payer lens. Government and private healthcare organizations collaborated to form the HFPP as a public-private partnership to combat fraud, waste, and abuse.

  • Competitive pay and benefits, flexible work schedule, collaborative inter-disciplinary environment where the best idea wins.

GDIT CAREERS

Opportunity Owned

Discover more at www.gdit.com/careers  

General Dynamics Information Technology is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class.

This position requires being fully vaccinated against COVID-19 by January 18, 2022 or the start date, if after January 18. Individuals who work in or reside in Texas or Montana or work outside of the United States may be excluded from this requirement.

The likely salary range for this position is $116,000 - $174,000, this is not, however, a guarantee of compensation or salary; rather, salary will be set based on experience, geographic location and possibly contractual requirements and could fall outside of this range.

View information about benefits and our total rewards program.

We are GDIT. The people supporting some of the most complex government, defense, and intelligence projects across the country. We deliver. Bringing the expertise needed to understand and advance critical missions. We transform. Shifting the ways clients invest in, integrate, and innovate technology solutions. We ensure today is safe and tomorrow is smarter. We are there. On the ground, beside our clients, in the lab, and everywhere in between. Offering the technology transformations, strategy, and mission services needed to get the job done.

GDIT is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class.