Manager - Fraud Waste and Abuse Special Investigations

The Manager- Fraud, Waste and Abuse Special Investigations leads the organization’s efforts to detect, investigate and prevent fraud, waste and abuse across international healthcare claims. This role is responsible for overseeing the end-to-end investigative function, guiding a team of investigators, and ensuring consistent, high-quality case management. The Manager drives strategic priorities, strengthens cross-functional partnerships and enhances investigative capabilities to reduce financial loss, mitigate risk and support regulatory compliance globally.

Responsibilities

• Oversee complex fraud investigations, including reviewing case strategies, findings and final reports.
• Lead a team of individuals responsible for detecting and investigating fraud in healthcare claims from around the world.
• Optimize performance with attention to savings realization, inventory management, process design and documentation, KPI development, and reporting.
• Identify opportunities or gaps in current processes and implement solutions to improve team performance and customer experience.
• Cultivate relationships with key business partners and relevant law enforcement agencies.
• Coordinate activities across departments (ex. FWA, Clinical, Legal, Customer Service, Claims) and external entities (ex. home plans or vendors).
• Develop capacity models and business cases to ensure support for growth.
• Deploy resources effectively between pre-payment prevention and post payment recovery capabilities.
• Increase awareness and training related to identifying and preventing fraud within the FWA team and the broader organization.
• Ensure timely resolution and notification of escalated cases.
• Track activity and produce reports to measure impact and document actions.
• · Support cross-functional projects and initiatives as a subject matter expert as needed.
• Support commercial teams in client meetings and finalist presentations as needed.
• Contact external 3rd parties through outbound call or email to obtain additional information or verify claim information.
• Validate accuracy of claim charges and initial processing decisions.
• Perform online research to fill in gaps in existing tools and understanding.

Requirements

• 5+ years of insurance industry or other relevant experience required.
• College degree or equivalent experience.
• Strong working knowledge of international health insurance claims.
• Knowledge of US Domestic health insurance claims is a plus.
• Prior experience identifying or investigating fraud, waste, and abuse is highly valued.
• Multi-lingual strongly preferred.
• Strong attention to detail and problem-solving skills.
• Excellent written and verbal communication skills.
• Demonstrated ability to build relationships and negotiate positive outcomes.
• Prior experience leading high performing teams in a fast-paced environment strongly preferred.
• Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
• Ability to deal with ambiguity and drive for resolution.
• Willingness and ability to learn and apply new skills.
• Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

Working conditions

• Flexibility to work in an office and/or at-home, remote office environment.
• Schedule flexibility is occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
• Physical Demands: Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.

This job description reflects management’s assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.