Sr Fraud, Waste and Abuse Investigator (Investigator Sr)

About the role

The Sr Fraud, Waste and Abuse Investigator (Investigator Sr) position is part-time telework eligible. The role supports the detection, prevention, investigation, mitigation, and reporting of fraud, waste, and abuse issues. Key responsibilities include conducting investigations, maintaining accurate records, preparing reports, and collaborating with various departments and external entities.

Responsibilities

• Analyze investigation results to determine if allegations are substantiated and coordinate appropriate actions.
• Maintain accurate records of all investigative activities and findings, ensuring timely and accurate documentation in the case management system.
• Create summaries and detailed reports of investigative findings, preparing documents for internal and external audiences and regulatory agencies.
• Prepare audit results letters for providers when overpayments are identified.
• Stay informed about health care industry trends impacting the organization and its health networks.
• Communicate with regulatory and law enforcement agencies as necessary.
• Assist with regulatory audit preparation.

Requirements

• Bachelor's degree in health care administration, criminal justice, or related field with 5 years of experience in health care-related investigations.
• Access to transportation for work away from the primary office approximately 15% of the time.

Qualifications

• Experience with medical billing and coding, medical terminology, and clinical documentation guidelines.
• Bilingual in English and one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).
• Preferred certifications: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar.

Skills

• Develops rapport and maintains effective working relationships with CalOptima Health's leadership and staff and external contacts.
• Works independently and exercises sound judgment.
• Communicates clearly and concisely, both orally and in writing.
• Manages multiple projects and identifies opportunities for collaboration.
• Utilizes computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job-specific applications/systems.

Benefits

• Comprehensive benefits package including CalPERS pension program and additional retirement packages.
• Tuition reimbursement and professional development opportunities.
• Flexible scheduling and a quality work-life balance.

Pay

The pay grade for this role is 310, ranging from $72,096 to $115,353 annually ($34.66 to $55.4582 hourly).

Schedule

This position is part-time telework eligible. If telework is approved, you must work within the State of California and come in to the Main Office in Orange, CA, at least two (2) days per week minimum.