Fraud, Waste & Abuse Program Manager

Location

Location: Hybrid:
This position has the possibility of being 100% remote.

Most of the positions at YCCO are hybrid, meaning they have the flexibility to work both remotely and in-person at YCCO's office in McMinnville, OR.

Department: Compliance

FLSA Status: Exempt (Salaried)

Division: Compliance

Physical Strength: Light (L)

Reports To: Compliance Officer

Work Location Type: Hybrid

Supervisory Role: No

Occasional Weekend Work: No

About Us: Yamhill Community Care is a nonprofit coordinated care organization dedicated to managing the healthcare for Medicaid members, covered under the Oregon Health Plan, in Yamhill County, as well as parts of Washington and Polk Counties. Our mission is to improve the quality of life of the communities we serve by coordinating effective care. Beyond healthcare, we also provide an Early Learning Hub, supporting families and children with essential resources and programs for early childhood development.

Together, we're building a unified healthy community that celebrates physical, mental, emotional, spiritual, and social well-being.

Learn more about Yamhill Community Care:

The Fraud, Waste & Abuse Program Manager is responsible for the design, implementation, and management of Yamhill Community Care’s (YCCO) Fraud, Waste, & Abuse (FWA) Program, providing expertise to staff in developing processes for tracking, investigating, and managing suspected FWA complaints.

• Develops and maintains a structure around a FWA and payment integrity program supported by policies, processes, procedures, workflows, and technology, in collaboration with the Compliance Officer and other applicable YCCO departments.
• Manages Fraud, Waste & Abuse Program, including maintenance of annual YCCO FWA Plan, Assessment and Handbook-related policies in collaboration with the Compliance Officer.
• At case intake, processes, prioritizes, analyzes, documents, tracks referrals and conducts background research, gathers supporting documentation, retrieves and reviews records, and coordinates with other individuals and departments, promptly.
• Proactively performs records and data retrieval from Third Party Administrator (TPA) and providers, data mining, analysis, and research to identify potential opportunities to investigate suspected FWA to support of a full range of investigative functions from case development to referral in a timely manner.
• Works closely with the YCCO Compliance Auditors on program integrity and FWA-related claims audits. Upon completion of such audit, presents report, including any over payments made, to Compliance Officer.
• Develop, translate, and execute strategies or functional / operational objectives for the company with regard to fraud, waste, and abuse.
• Assist in the development and presentation of compliance and FWA training presentations.
• Serve as primary point of contact for external oversight agencies to include the OHA Office of Program Integrity and Department of Justice Medicaid Fraud Control Unit.
• Serve as a member of the YCCO Compliance Committee and report-out on FWA matters.
• Manage and oversee the preparation and submission of FWA regulatory reporting requirements to OHA, including quarterly and annual reports and annual FWA deliverables.
• Develops and maintains / updates FWA-related policies and procedures.
• Performs matrixed work with other YCCO departments as needed, including Health Plan Operations and Finance.
• Regularly attend fraud-related meetings with OHA.
• Takes a matrixed approach to all duties and works in partnership with other YCCO Departments to achieve YCCO’s mission.
• Communicates updates on assignments to supervisors, managers, and other departments and committees.
• L…