Fraud Waste Abuse; FWA Specialist II; Defined Term

Remote, California

We believe every candidate deserves thoughtful consideration. That’s why we do not use AI or automated systems to review applications. Every application is reviewed by a real human member of our team. Because we take the time to give each submission the attention it deserves, our review process may take a little longer — and we genuinely appreciate your patience as we work through applications carefully and respectfully.

While we encourage all interested applicants to apply, we do give priority to those who live in or near our service counties:
Santa Cruz, Monterey, Merced, San Benito, and Mariposa. Our mission of accessible, quality health care guided by local innovation leads everything we do, and having team members who are connected to the communities we serve strengthens our ability to deliver on that commitment.

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.

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

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.

• 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

• 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
• U…