Risk Manager

Responsibilities

• Lead fraud, waste, and abuse oversight activities to strengthen program integrity and support healthcare risk management objectives.
• Build and maintain effective working relationships with Medicaid program integrity representatives, including participation in collaborative meetings and timely responses to inquiries.
• Direct investigative case management from initial referral through documentation, resolution, reporting, and recovery follow-up.
• Use data mining, claims analysis, and pattern review to identify suspicious billing activity, unusual utilization trends, and new investigation opportunities.
• Conduct detailed investigations involving providers, members, subcontractors, and other relevant parties while ensuring complete and well-supported case records.
• Prepare clear investigative summaries, audit findings, and regulatory reports covering all stages of case development and outcomes.
• Cook up coordination with compliance partners, public agencies, law enforcement, and oversight entities to support referrals, information requests, and enforcement actions.
• Monitor adherence to state and federal fraud prevention requirements and communicate applicable obligations to internal teams and external stakeholders.
• Support overpayment recovery efforts by identifying financial exposure, documenting findings, and working with appropriate parties to pursue resolution.
• Perform additional risk and compliance duties as needed to meet departmental priorities and business needs.

Requirements

• At least 1 year of experience in risk management, fraud investigation, compliance investigations, or healthcare program integrity.
• Background in healthcare fraud, anti-fraud operations, fraud analytics, or related investigative work within a regulated environment.
• Knowledge of risk analysis, risk management strategies, and compliance management practices.
• Ability to perform data mining and interpret claims or billing patterns to detect potential fraud, waste, or abuse.
• Familiarity with state and federal regulatory requirements tied to investigations, compliance functions, and reporting obligations.
• Strong due diligence, documentation, interviewing, and analytical skills with careful attention to detail.
• Ability to communicate findings clearly to providers, internal stakeholders, regulatory contacts, and external partners.
• Experience collaborating across compliance, audit, and investigative teams while managing multiple priorities effectively.

Qualifications

Commensurate with experience.

Skills

Not specified.

Benefits

Not specified.

Pay

TBD.

Schedule

TBD.