Central California Alliance for Health · 4 days ago
Fraud Waste Abuse (FWA) Specialist II (Defined Term)
California, United States
Full-time
Hybrid
Mid Level
$70K/yr - $112K/yr
3+ years expCentral California Alliance for Health is a regional non-profit health plan committed to providing accessible, quality health care. They are seeking a Fraud Waste Abuse (FWA) Specialist II to conduct investigations into fraud, waste, and abuse, assist with program integrity activities, and support compliance efforts in the healthcare sector.
GovernmentHealth CareHealth InsuranceHospital
No H1B
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
Qualification
Required
Experience conducting investigations into alleged fraud, waste and abuse (FWA) in a managed care or healthcare environment
Knowledge of HIPAA regulations and committed to maintaining data privacy and security
Proficient in Microsoft Office, especially Word and Excel
Acute attention to detail and data accuracy
Experience working remotely and knows how to self-motivate while staying closely connected to their team
Excellent multitasking skills and the ability to manage multiple projects at once in a deadline-driven environment
Knowledge of the Medi-Cal and Medicare Advantage programs and related regulations
Knowledge of research, analysis, and reporting methods
Knowledge of 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
Ability to conduct thorough investigations and produce well-documented and accurate conclusions and recommendations
Ability to develop, implement, and monitor corrective action plans with guidance from the Program Integrity Specialist III or Program Integrity Manager
Ability to understand and interpret provider contracts and provider payment system processes
Ability to identify and research relevant legal materials, analyze and interpret legal and contractual language
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
Benefits
Medical, Dental and Vision Plans
Ample Paid Time Off
12 Paid Holidays per year
401(a) Retirement Plan
457 Deferred Compensation Plan
Robust Health and Wellness Program
Onsite EV Charging Stations
Company
Central California Alliance for Health
The Alliance is a state-funded health plan that provides Medi-Cal insurance to Mariposa, Merced, Monterey, San Benito & Santa Cruz counties.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Michael Schrader
Chief Executive Officer
Lisa Ba
Chief Financial Officer
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