Job Description

Wize Solutions is seeking a Compliance Consultant with deep expertise in Hospital Compliance , particularly in Fraud, Waste, and Abuse (FWA)—to support the development of a next-generation, agentic (AI-driven and autonomous) solution designed to proactively detect, prevent, and report FWA in healthcare systems.

The ideal candidate will have substantial experience in compliance operations and FWA investigations within hospital environments and will work closely with data scientists, product managers, and engineers to ensure the solution aligns with real-world compliance challenges and regulatory standards.

Key Responsibilities:

• Serve as the subject matter expert (SME) on hospital compliance and FWA throughout the product development lifecycle.
• Collaborate with technical teams to translate regulatory frameworks and hospital workflows into actionable system requirements.
• Define use cases, risk scenarios, red flags, and control mechanisms to inform the AI’s training and behavior.
• Validate the efficacy of AI models against regulatory expectations and historical case patterns.
• Lead mock audits, scenario testing, and compliance simulations to assess the agentic system’s response accuracy.
• Contribute to regulatory content integration, including rules from CMS, OIG, DOJ, and commercial payer guidelines.
• Provide guidance on FWA detection protocols, investigation workflows, and reporting standards.
• Support customer discovery and market validation efforts by engaging with compliance officers, hospital administrators, and payers.
• Participate in client presentations and demos, offering compliance credibility and regulatory insight.

Required Qualifications:

• Bachelor’s degree in healthcare administration, Law, Compliance, or related field (Master’s, JD, or MPH preferred).
• Minimum 5 years of direct experience in hospital compliance, with a strong background in detecting and reporting FWA in public programs (Medicare, Medicaid or VA).
• Demonstrated knowledge of federal healthcare regulations, including the False Claims Act, Anti-Kickback Statute, Stark Law, HIPAA, and CMS FWA guidelines.
• Certified in Healthcare Compliance (CHC), Certified Fraud Examiner (CFE), or Certified in Healthcare Privacy and Security (CHPS)/
• Experience collaborating with product or technical teams in healthcare IT, compliance software, or analytics solutions.
• Experience working with or within CMS, MACs, state Medicaid agencies, or contractors such as UPICs or ZPICs.
• Strong communication and documentation skills with the ability to interface between clinical, compliance, and technical stakeholders.

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