[Hiring] Manager - Prepayment Fraud, Waste, and Abuse Operations @Gainwell Technologies LLC

Role Description

The Prepayment Fraud, Waste, and Abuse (FWA) Operations Manager is responsible for leading and optimizing Prepayment FWA operations to ensure high-quality investigative reviews, research, and case management services. The role provides strategic and operational oversight to drive program integrity, regulatory compliance, operational excellence, and continuous process improvement. As a key liaison between clients, medical consultants, compliance teams, and business partners, the manager collaborates across functions to identify and mitigate emerging risks, address operational issues, and enhance fraud prevention and detection initiatives.

• Provide leadership and oversight for Prepayment Fraud, Waste and Abuse operations, ensuring achievement of quality, productivity, timeliness, compliance, and contractual performance objectives while fostering a culture of accountability, collaboration, continuous learning, and operational excellence.
• Lead, develop, and optimize team performance through coaching, performance management, workforce planning, training, and employee development, while serving as the escalation point for complex investigations, policy interpretation, and high-risk issues.
• Establish and maintain investigative governance, documentation standards, and case review methodologies to ensure consistent, accurate, and compliant research and investigative practices across the operation.
• Monitor operational performance, quality outcomes, investigative trends, and emerging fraud, waste, and abuse risks to identify process gaps, mitigate risk, and drive data-informed recommendations and continuous improvement initiatives.
• Partner with clients, medical consultants, compliance teams, legal representatives, and other stakeholders to support program integrity objectives, resolve complex issues, and lead the implementation of regulatory changes, business requirements, system enhancements, and operational improvements.

Qualifications

• 5+ years of experience in healthcare operations, program integrity, fraud, waste and abuse investigations, claims analysis, payment integrity, auditing, compliance, or a related healthcare field.
• 2+ years of leadership experience managing investigative, analytical, healthcare operations, or program integrity teams, with a demonstrated ability to drive performance and operational results.
• Strong knowledge of healthcare regulations, billing requirements, claims processing, fraud, waste and abuse detection methodologies, and program integrity operations.
• Experience analyzing claims, provider billing activity, authorization records, healthcare data, and investigative findings to identify trends, risks, root causes, and opportunities for improvement.
• Proven ability to lead complex operational initiatives, manage competing priorities, solve problems, and implement process improvements in a fast-paced environment.
• Excellent analytical, communication, stakeholder management, and relationship-building skills, with experience collaborating across clients, medical consultants, compliance organizations, and cross-functional business partners.

Requirements

• Must reside within an hour of California State Capital.
• Regular collaboration with clients, medical consultants, compliance partners, and operational leadership.
• Focus on quality, operational performance, regulatory compliance, and continuous improvement.
• Leadership responsibility for investigative operations, employee development, and program integrity initiatives.
• Applications for this position will be accepted until 10/26/2026.

Benefits

• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Variety of leadership and technical development academies to help build your skills and capabilities.