Sr Fraud, Waste and Abuse Investigator (Investigator Sr)

Join us in this amazing opportunity with a mission-driven, community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person.

About the role

As a Sr Fraud, Waste and Abuse Investigator, you will be an integral part of our OOC - Fraud & Waste team, helping to shape the future of healthcare. This position supports the detection, prevention, investigation, mitigation, and reporting of fraud, waste, and abuse (FWA) issues. You will conduct investigations of medical providers, pharmacies, CalOptima Health, health networks, and members from case management to resolution, identifying overpayments of funds. Additionally, you will collaborate with internal departments, legal counsel, medical directors, and external entities to maintain appropriate anti-fraud oversight.

This position has been approved for partial telework. If telework is approved, you are required to work within the State of California and come into the main office in Orange, CA, at least two days per week.

Responsibilities

• Analyze investigation results to ascertain if allegations have been corroborated and determine appropriate steps to address issues.
• Maintain accurate recordkeeping of all investigative activities and findings, ensuring timely and accurate documentation in the case management system.
• Prepare summary and detailed reports of investigative findings for internal and external audiences, including regulatory agencies.
• Prepare audit results letters to providers when overpayments are identified.
• Stay current with developments in the healthcare industry regarding FWA trends that may impact the organization and its delegated health networks.
• Interact with regulatory and/or law enforcement agencies as needed.
• Assist with preparation efforts for regulatory audits.
• Participate in a mission-driven culture focused on high-quality performance, customer service, consistency, dignity, and accountability.
• Collaborate with the team to support short- and long-term department goals and priorities.
• Perform end-to-end investigations, including witness interviews, data and situational analysis, contract and program regulation research, provider and member education, and recommendations for outcomes.
• Adhere to the CalOptima Health FWA program mission statement.
• Research and understand relevant offenses, conducting efficient and effective investigations concerning alleged offenses.
• Obtain information and evidence through observation, record examination, interviews, and other appropriate methods.
• Prepare correspondence for multiple assignments, remaining objective, accurate, and tactful in communication.
• Complete other projects and duties as assigned.

Requirements

• Bachelor’s degree in healthcare administration, criminal justice, or a related field, plus 5 years of experience in healthcare-related investigations; an equivalent combination of education and experience may also qualify.
• Access to means of transportation for work away from the primary office approximately 15% of the time.
• Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar certification completion; currently pursuing a related certification or having completed more than half of the requirements towards certification.

Preferred 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).

Skills

• Develop rapport and maintain effective working relationships with leadership, staff, and external contacts at all levels and diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule, including availability for evening and weekend events.
• Organize, analyze, problem-solve, and manage projects effectively.
• Work efficiently in a fast-paced environment and manage multiple projects.
• Identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job-specific applications/systems.

Physical Requirements

• Ability to visually read information from computer screens, forms, and other printed materials.
• Ability to speak clearly in conversation and general communication.
• Hearing ability for verbal communication via telephone and face-to-face interactions.
• Manual dexterity for typing, writing, standing, reaching, flexibility, body movement for bending, crouching, walking, kneeling, and prolonged sitting.
• Lifting and moving objects, patients, and/or equipment weighing 10 to 25 pounds.

Work Environment

• If located at the 505 Building or a remote work location: Work is typically indoors and sedentary, subject to schedule changes and variable work hours, with travel as needed. The noise level is usually moderate.
• If located at PACE: Work is typically indoors in a clinical setting serving the frail and elderly. There may be harmful or hazardous environmental conditions. The noise level is usually moderate to loud.
• If located in the community: Work is typically indoors and sedentary, subject to schedule changes and variable work hours, with travel as needed. Occasional outdoor work in varied temperatures. There may be harmful or hazardous environmental conditions. The noise level is usually moderate to loud.

Benefits

• Competitive compensation: Pay Grade 310 - $72,096 - $115,353 ($34.66 - $55.4582 per hour), with the final salary based on education, experience, skills, and internal equity.
• Comprehensive benefits package and CalPERS pension program.
• Generous PTO program and a focus on work-life balance.
• Wellness programs and tuition reimbursement.
• Professional development and career growth opportunities.
• Flexible scheduling.

Why Join Us?

We believe that diverse perspectives drive innovation. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare. This role offers the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.