Fraud Waste Abuse (FWA) Specialist II (Defined Term)

Central California Alliance for Health

19h•Hybrid

About The Position

We have an opportunity to join the Alliance as a Fraud Waste Abuse (FWA) Specialist II (also known as a Program Integrity Specialist II) in the Compliance Department. Reporting to the Program Integrity Manager, this position: Conducts medium- to high-complexity investigations into alleged fraud, waste, and abuse (FWA) referred to or identified by the Alliance FWA Prevention (FWAP) Program and/or Special Investigations Unit (SIU) Assists with the administration of medium- to high-complexity Program Integrity activities Supports the execution and oversight of moderate- to high-complexity privacy-related compliance activities Performs other duties as assigned ABOUT THE TEAM The Compliance Division interprets requirements, mitigates risk, and holds stakeholders accountable, protecting the organization’s integrity and members' access to quality healthcare. We are the team that helps employees understand and follow the complex rules and requirements to meet our important compliance obligations. In short, we define and support the Alliance's Culture of Compliance internally and with our external healthcare partners. We perform internal audits and monitoring to help us maintain a compliance program that is always up-to-date with ever-evolving compliance rules and obligations. We also handle and investigate internal concerns related to HIPAA, fraud, waste, and abuse, and conduct prevention and detection activities.

Requirements

Knowledge of: Research, analysis, and reporting methods
General health care compliance and privacy principles, quality improvement practices, and related audit techniques
Proficiency with Windows-based PC systems and Microsoft Word, Outlook, PowerPoint and Excel (including pivot tables), and Adobe Acrobat
Ability to: Quickly understand Alliance functions and roles and responsibilities related to oversight agencies and learn and apply policies, procedures, and guidelines, including Medi-Cal and Medicare guidelines
Conduct thorough investigations and produce well-documented and accurate conclusions and recommendations
Develop, implement, and monitor corrective action plans with guidance from the Program Integrity Specialist III or Program Integrity Manager
Understand and interpret provider contracts and provider payment system processes
Identify and research relevant legal materials, analyze and interpret legal and contractual language
Education and Experience: Bachelor’s degree in Healthcare Administration, Public Health Administration, Criminal Justice, Finance, or a related field and a minimum of three years of program integrity, auditing, quality improvement, or compliance-related experience in the healthcare industry (a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying.

Nice To Haves

Has experience conducting investigations into alleged fraud, waste and abuse (FWA) in a managed care or healthcare environment
Is knowledgeable of HIPAA regulations and committed to maintaining data privacy and security
Is proficient in Microsoft Office, especially Word and Excel
Has an acute attention to detail and data accuracy
Has experience working remotely and knows how to self-motivate while staying closely connected to their team
Has excellent multitasking skills and the ability to manage multiple projects at once in a deadline-driven environment
Has knowledge of the Medi-Cal and Medicare Advantage programs and related regulations

Responsibilities

Conducts medium- to high-complexity investigations into alleged fraud, waste, and abuse (FWA) referred to or identified by the Alliance FWA Prevention (FWAP) Program and/or Special Investigations Unit (SIU)
Assists with the administration of medium- to high-complexity Program Integrity activities
Supports the execution and oversight of moderate- to high-complexity privacy-related compliance activities
Performs other duties as assigned