Fraud, Waste, and Abuse Subject Matter Expert

3 weeks ago

Rockville, United States Turning Point Global Solutions Full time

We are seeking a highly skilled and experienced Fraud, Waste, and Abuse (FWA) Subject Matter Expert (SME) who has expertise in HealthCare policies and regulations, with deep knowledge in FWA case management associated with Medicare and Medicaid programs. The FWA SME will be responsible for providing expert guidance and oversight from a policy and compliance perspective to the project team and to the investigative processes as outlined in the Program Integrity Manual (PIM). As part of the program management team, the FWA SME will influence the design of the system to incorporate proactive measures for identifying potential FWA scenarios.

     Details:

  • Specialty: Government Contracting Services
  • Location:  Rockville, MD
  • Schedule: Negotiable
  • Salary: commensurate with Experience, Skills, and Education

TurningPoint offers a robust benefits package that includes health, dental, and vision benefits - 100% towards the employee and 80% towards the employee’s immediate dependent’s standard coverage paid by TurningPoint, a retirement plan with an employer match program, life, AD&D, and disability coverage, and various voluntary benefits.

      Job Responsibilities:

  • Serves as an experienced source of knowledge, technique, or expertise in Medicare/ Medicaid FWA and associated laws, regulations, and guidelines.
  • Applies expertise to support the organization’s vision and strategic direction.
  • Understands, articulates, and implements best practices related to infusing FWA protections into system operations.
  • Leads and/or is an active participant in design meetings requiring Medicare/Medicaid FWA expertise.
  • Guides resolving business needs and actively participates in all phases of the software development life cycle
  • Conducts risk assessments and develops and implements policies, procedures, and controls aimed at preventing and detecting fraudulent activities.
  • Provides expert guidance and training to project teams on the investigative processes and best practices.
  • Supports the project team with case management activities and oversees remediation efforts to address identified issues and prevent recurrence.
  • Supports and coordinates with investigative resources.
  • Ensures compliance with relevant laws, regulations, and compliance standards related to fraud prevention and detection.
  • Collaborates with internal stakeholders, external partners, and regulatory agencies as needed to address fraud-related concerns.
  • Stays informed about emerging trends, technologies, and best practices in fraud prevention and detection.
  • Researches, evaluates, and recommends new solutions to address unmet or new regulatory requirements or to enhance capabilities
  • Analyzes customer requirements and works with the technical team to meet customer needs.

    Required Skills:

  • Demonstrated Medicare/Medicaid SME, particularly with regard to FWA.
  • In-depth knowledge of the Medicare and Medicaid Program Integrity Manual (PIM).
  • Strong analytical skills and attention to detail, with the ability to identify patterns, anomalies, and discrepancies in data and documentation.
  • Excellent communication and interpersonal skills, with the ability to effectively collaborate with diverse stakeholders and convey complex concepts to non-technical audiences.
  • Proficiency in relevant tools and technologies for fraud detection, investigation, and reporting.
  • Demonstrated ability to work independently, prioritize tasks, and manage multiple tasks effectively.
  • Strong organizational and project management skills


    Education and Experience:

  • Bachelor’s degree in Engineering, Computer Science, Systems, Business, Public Health, or related scientific/technical discipline.
  • 15+ years of experience in fraud prevention, detection, and investigation, with a proven track record of success.
  • Must have lived in the United States at least three (3) out of the last five (5) years.
  • Must be able to pass background investigations.

     

    Nice to have:

  • Advanced degrees or specialized training in healthcare compliance or healthcare administration.
  • Certified in Healthcare Privacy and Security, CHPS.
  • Certified in Healthcare Compliance (CHC) or Certified Compliance Professional (CCP).
  • SAFe (Agile) experience.

About the Company:

Turning Point Global Solutions (TurningPoint) is a fast growing system integration, information technology services company that caters to federal, state, and local government and commercial clients. We specialize in full lifecycle system integration and software engineering services involving digital transformation and solution engineering in healthcare IT and telecom business verticals. Our services include software development, software integration, business process outsourcing, and professional services. Founded in 2002, TurningPoint prides itself in a heritage of innovation and strong professional services capabilities, enabling it to provide a full suite of mission-critical solutions in a timely and cost-effective manner. TurningPoint processes are independently appraised at CMMI Maturity Level 5 for Development.
All qualified applicants are considered for employment without discrimination due to race, gender, religion, age, marital status, national origin, disability, sexual orientation, or any other characteristic protected by federal, state, or local law. This policy extends to all aspects of employment with TurningPoint, including, but not limited to, recruitment, hiring decisions, assignment, advancement, compensation, benefits, retention, and termination.

 

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