Sr. Investigator, Fraud, Waste and Abuse

About the role

The Sr. Investigator, Fraud, Waste and Abuse at CalOptima is a mission-driven position aimed at detecting, preventing, investigating, mitigating, and reporting on fraud, waste, and abuse in healthcare. Reporting to the OOC - Fraud & Waste team, this role involves supporting the organization's commitment to excellence and dignity in healthcare.

Responsibilities

• Conducts investigations of medical providers, pharmacies, CalOptima Health, health networks, and members from case management to resolution, identifying overpayment of funds.
• Works with internal departments, legal counsel, medical directors, and external entities to achieve and maintain appropriate anti-fraud oversight.
• Researches and understands relevant offenses, conducts efficient and effective investigations, and detects or verifies suspected violations.
• Obtains information and evidence through various methods, prepares correspondence, and communicates with others tactfully.
• Analyzes investigation results, determines appropriate steps to address issues, maintains accurate recordkeeping, and prepares reports for internal and external audiences and regulatory agencies.
• Prepares audit results letters to providers for overpayments, stays current with FWA trends, and interacts with regulatory and law enforcement agencies as needed.
• Assists with regulatory audit preparation efforts.

Requirements

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

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).
• Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or equivalent certification.

Skills

• Develops rapport and establishes effective working relationships with CalOptima Health's leadership and staff and external contacts.
• Communicates clearly and concisely, both orally and in writing.
• Manages multiple projects and identifies opportunities for internal and external collaboration.
• Motivates and leads multi-program teams and external committees/coalitions.
• Utilizes computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job-specific applications/systems.

Benefits

• Competitive compensation with a pay grade range of $72,096 - $115,353.
• A comprehensive benefits package including CalPERS pension program and additional retirement packages.
• Various wellness programs, tuition reimbursement, professional development opportunities, career development opportunities, flexible scheduling, and more.

Physical Requirements

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