Payment Integrity and Fraud, Waste and Abuse Team Lead

Team Lead, Payment Integrity and Fraud, Waste and Abuse

Join Pacific Source and help our members access quality, affordable care!

Pacific Source is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. Pacific Source values the diversity of our community, including those we hire and serve.

We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

The Payment Integrity and Fraud, Waste and Abuse (FWA) Team Lead is responsible for overseeing the daily operations of Pacific Source's Payment Integrity and FWA programs. This role provides leadership for Payment Integrity and FWA activities while supporting the development and execution of pre-payment and post-payment initiatives designed to ensure payment accuracy, regulatory compliance, and responsible stewardship of healthcare resources. The Team Lead serves as a subject matter expert in payment integrity operations, fraud prevention, audit activities, provider recoveries, and regulatory requirements.

This position works closely with Claims, Compliance, Finance, Provider Relations, and external vendors to identify opportunities for cost avoidance, over payment recovery, process improvement, and program effectiveness.

Essential Responsibilities:

• Provide direct supervision, coaching, performance management, and professional development for assigned Payment Integrity and FWA staff.
• Supervise and direct payment integrity claims adjustment activities, ensuring timely and accurate implementation of claim corrections, recoveries, and financial adjustments.
• Oversee recovery inventory management and ensure identified over payments, audit findings, and recovery opportunities are appropriately processed, tracked, and resolved.
• Coordinate daily work activities, workload prioritization, inventory management, and resource allocation across payment integrity functions.
• Support the execution and on-going operations of pre-payment and post-payment payment integrity programs, including audits, claims reviews, recoveries, and fraud prevention activities.
• Oversee the investigation, tracking, documentation, and resolution of potential fraud, waste, and abuse referrals and cases.
• Monitor payment integrity performance metrics and recovery results and prepare reports for leadership, compliance committees, and regulatory agencies as needed.
• Implement and maintain payment integrity policies, procedures, workflows, and operational controls.
• Ensure compliance with applicable federal and state regulations, CMS requirements, contractual obligations, and internal policies.
• Serve as a primary operational liaison between Payment Integrity, Compliance, Claims Operations, Provider Relations, Finance, and Special Investigations functions.
• Coordinate day to day operational activities with external vendors supporting audit, recovery, analytics, and fraud detection programs and monitor adherence to established service levels.
• Review audit findings, recovery opportunities, and investigative outcomes to ensure consistency, accuracy, and adherence to established standards.
• Support preparation and submission of regulatory reporting requirements related to fraud, waste, abuse, and payment integrity activities.
• Participate in internal and external audits and assist with corrective action planning and implementation.
• Identifying emerging risks, payment vulnerabilities, billing trends, and opportunities for program improvement and escalate recommendations to leadership.
• Lead or participate in departmental projects, process improvement initiatives, and cross-functional work groups.
• Actively participate as a key member of management and leadership meetings.
• Represent Payment Integrity on internal committees and work groups as assigned.
• Coordinate business activities by…