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

This is a Defined Term position, which is designated by the Alliance and is a position of limited duration. Defined Term employees are usually hired to work in a specific department on specific long-term project work until the work is completed or to a specific end date not to exceed December 31, 2026. This is a Defined Term and fully benefited 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.

WHAT YOU'LL BE RESPONSIBLE FOR

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.

THE IDEAL CANDIDATE

• 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

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description and list of requirements, click here

• 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.

OTHER INFORMATION

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

The full compensation range for this position is listed by location below.

The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).

Typical areas in Zone 1: Bay Area, Sacramento, Los Angeles area, San Diego area

Typical areas in Zone 2: Fresno area, Bakersfield, Central Valley (with the exception of Sacramento), Eastern California, Eureka area