Senior Fraud, Waste, Abuse (FWA) Investigator

California Salary Range: $97,534 - $141,424

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

As a member of our Compliance team, the Sr. Fraud, Waste, Abuse Investigator will help ensure CenCal Health's compliance with applicable laws, rules, and regulations, with specific responsibility for the ongoing administration and operation of our internal Fraud, Waste and Abuse (FWA) program. The FWA Investigator will assist with the implementation of a compliance program to effectively prevent and detect violation of applicable laws and regulations which will protect the organization from liability of fraudulent or abusive practices. The FWA Investigator will manage, follow up and ensure resolution of the investigation.


Duties & Responsibilities

Perform investigations into potential/actual FWA, with duties including but not limited to:

• Receiving and investigating allegations/incidents of FWA from external and internal sources; Leads and manages the intake referral from internal and external sources and developing leads presented to Compliance to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence
• Leads, manages, and conducts preliminary investigations, comprehensive interview with witness (member, provider, and internal staff), within the mandated period of time required by either state and/or federal contracts and/or regulations
• Manages and performs data mining and analysis to detect aberrancies and outliers in claims and developing new queries and reports to detect potential waste, abuse, and fraud
• Leads and performs sampling methodologies for medical records request/reviews.
• Leads and manages the preparation of detailed preliminary and extensive investigation referrals to state and/or federal regulatory and/or law enforcement agencies when potential fraud, waste, or abuse is identified as required by regulatory and/or contract requirements and
• Ensures FWA reporting is of the highest administrative quality and submitted in a timely manner; and

• Completes all necessary investigative work for resolution of potential/actual FWA cases.
• Provides recommendations and guidance to leadership, management, and stakeholders on remediation of areas of non-compliance and/or whether recoupment should be conducted.
• Serves as a qualified compliance resource for interpretation, guidance, and education of health plan regulations related to FWA to ensure compliance with contractual requirements, federal and state statutes and regulations, and regulatory program requirements.
• Works with relevant subject matter experts to implement appropriate ongoing monitoring, when applicable.
• Lead the development, facilitation, coordination, and evaluation of FWA initiatives and day-to-day operations, with duties including but not limited to:
• Develops, implements, maintains and reviews FWA procedures, workflows, templates documentation required for investigations, investigation-related correspondence, and CAPs;
• Maintains a secure centralized system for FWA case information management, ensuring an accurately maintained FWA case log;
• Maintains FWA report/activity reminder systems and notifying staff of deliverables;
• Prepares reports to committees/workgroups, state agencies, and law enforcement, as needed;
• Informs Compliance leadership of instances of non-compliance identified in/through CenCal Health operations, as needed;
• Develops and facilitates FWA training, education and awareness activities;
• Prepares for internal/external audits, and audit finding responses and corrective action plans;
• Coordinates with departments to modify existing and/or identify and implement new internal controls including but not limited to auditing and monitoring to strengthen the health plan's FWA activities.
• Maintains current awareness of healthcare and health plan compliance laws and regulations, as well as related industry developments

Assists with the routine activities involved in the maintenance of an internal audit program, with duties including but not limited to:

• Assists in the implementation and maintenance of an internal audit program to ensure compliance with federal and state statutes, regulations, and program guidance for all lines of business, including auditing of data received from delegates;
• Supports the audit program through the development and implementation of ongoing risk assessments, audit tools and policies and procedures;
• Serves as the lead representative for all external audits; duties include analyzing information, identifying, and resolving deficiencies, developing reports, and formulating recommendations for corrective action.

Performs administrative and staffing duties in support of Compliance department leadership, with duties including but not limited to:

• Staffs/organizes FWA Workgroups by preparing the agenda, notes and other related documentation, and maintaining secure centralized records.

• Prepares documents for administrative quality, preparing correspondence and completing outside agency documentation;
• Provides coverage for Compliance staff duties during absences

• Other duties as assigned

Knowledge/Skills/Abilities

• Advanced knowledge and experience working on various approaches to fraud, waste, and abuse;
• Knowledge of health care industry, health care regulatory policies, Medi-Cal, principles of health care planning and administration is highly preferred;
• Knowledge and proficient in claims adjudication standards is highly preferred;
• Knowledge of medical terminology and billing/coding systems is highly preferred;
• Knowledge of research, analysis, and reporting methods,
• Ability to work independently with minimal supervision, and manages a high volume of assignments;
• Ability to analyze and interpret regulatory and contractual language;
• Ability to write and speak effectively, clearly, concisely and professionally with committees, providers, members, executives, co-workers, external agencies and the public;
• Ability to ensure high administrative and service quality;
• Ability to define issues, interpret data and evaluate options;
• Ability to effectively prioritize multiple tasks and deadlines, with flexibility and capacity to identify and administer competing operational priorities in a changing environment with creativity and resourcefulness;
• Ability to manage information effectively (logical and sequential), and organize, produce and maintain accurate records and effective filing systems;
• Ability to synthesize and interpret a wide range of information, and interpret policies, standards, and guidelines.
• Ability to handle information that is considered personal and confidential to with integrity and confidentiality
• Attention to detail and accuracy is a must for this position.

Education & Experience

• Bachelor's degree in finance and accounting, Auditing, Compliance, Public Health Administration, Business Administration or a closely related field
• RN or nursing degree or certification preferred.
• Coding experience preferred.
• Three (3)- to five (5) years' experience conducting comprehensive health care fraud investigations, interacting with state, federal and local law enforcement agencies.
• Must have experience working on various approaches to fraud, waste, and abuse.
• Must have time and/or task management experience.
• Must have experience in the creation and preparation of reports and presentations.
• Must have experience hosting small to large stakeholder meetings.
• Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), and/or Accredited Healthcare Fraud Investigator (AHFI) (preferred).