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Sr Manager, Fraud, Waste and Abuse (Investigations) (Sr Manager I)
GovernmentJobs.com, Orange, California, United States, 92613
Sr Manager, Fraud, Waste and Abuse (Investigations) (Sr Manager I)
CalOptima Health is seeking a highly motivated Sr Manager, Fraud, Waste and Abuse (Investigations) (Sr Manager I) to join our team. The Sr Manager I for Fraud, Waste and Abuse (FWA) will be responsible for leading the team of CalOptima Health investigators to detect, investigate and mitigate FWA issues. The incumbent will ensure investigations are handled effectively and in a timely manner and will engage with regulatory agencies. The incumbent will partner with the director in long-term strategy planning to accomplish the department's goals and mission to enhance the program and payment integrity of the organization. Position Information: Department: Office of Compliance Salary Grade: 316 - $120,881 - $193,410 ($58.12 - $92.9856) Work Arrangement: Partial Telework This position is eligible for telework in California. Duties & Responsibilities: 45% - Leadership Functions Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department. Hires, manages, trains, supports, develops and evaluates direct reports. Directs work assignments, measures results and initiates personnel actions. Ensures that team members are trained and equipped with the necessary skills and resources. Collaborates with the director in departmental budgeting activities. Oversees the planning, scoping and execution of audits and the development of audit tools; ensures alignment with organizational goals and regulatory requirements. Oversees the planning, scoping and execution of investigations and the development of investigative tools; ensures alignment with organizational goals and regulatory requirements. Assists the director on development of the annual FWA risk assessment and Anti-Fraud, Waste and Abuse Plan. Assists department leadership in the management of critical business risks by communicating best practices, promoting process improvement, and monitoring remediation activities. 35% - Program Oversight Provides expertise and guidance to staff, management and other department areas on sensitive and complicated program integrity concerns, oversight and referrals. Creates and manages effective monitoring of ongoing investigations, including quality control, timeliness and business relations to continually evaluate FWA related activities. Performs reviews of investigations for sufficiency of content and documentation and escalates where appropriate. Prepares timely and accurate reporting on investigations, including scope, activities, methodologies, observations, deficiencies, recommendations and remediation activities. Presents investigative reports including findings, risks and recommendations to senior management. Collaborates with business areas to enhance systems, workflows and internal controls. Identifies benchmarking standards (leading practices) for identifying potential control gaps and/or opportunities for improving efficiency and compliance. Proposes recommendations for enhancing operational efficiency and identifying other areas of improvement. Provides excellent customer service by addressing concerns promptly and delivering actionable, professional insights. 15% - Investigative Activities Performs investigation activities for complex cases. Partners with staff in performing investigations of difficult cases. 5% - Other Completes other projects and duties as assigned. Minimum Qualifications: Bachelor's degree in business administration, accounting, health information management, or another related field PLUS 5 years of relevant work experience in health care investigations required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. 5 years of managerial experience within a managed care health plan in audits or investigations, or as an outside consultant engaged to perform audit work for a managed care health plan required. Have access to means of transportation for work away from the primary office approximately 15% of the time. Preferred Qualifications: Master's degree. Required Licensure / Certifications: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI) or similar certification completion, currently pursuing a related certification or has completed more than half of the requirements towards a certification. Knowledge & Abilities: Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. Work independently and exercise sound judgment. Communicate clearly and concisely, both orally and in writing. Work a flexible schedule; available to participate in evening and weekend events. Organize, be analytical, problem-solve and possess project management skills. Work in a fast-paced environment and in an efficient manner. Manage multiple projects and identify opportunities for internal and external collaboration. Motivate and lead multi-program teams and external committees/coalitions. Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Physical Requirements (With or Without Accommodations): Ability to visually read information from computer screens, forms and other printed materials and information. Ability to speak (enunciate) clearly in conversation and general communication. Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions. 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 10 to 25 pounds Work Environment: If located at the 500, 505 Building or a remote work location: Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. There are no harmful environmental conditions present for this job. The noise level in this work environment 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 present for this job. The noise level in this work environment is usually moderate to loud. If located in the Community: Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. Employee will occasionally work outdoors in varied temperatures. There may be harmful or hazardous environmental conditions present for this job. The noise level in this work environment is usually moderate to loud. About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 4
CalOptima Health is seeking a highly motivated Sr Manager, Fraud, Waste and Abuse (Investigations) (Sr Manager I) to join our team. The Sr Manager I for Fraud, Waste and Abuse (FWA) will be responsible for leading the team of CalOptima Health investigators to detect, investigate and mitigate FWA issues. The incumbent will ensure investigations are handled effectively and in a timely manner and will engage with regulatory agencies. The incumbent will partner with the director in long-term strategy planning to accomplish the department's goals and mission to enhance the program and payment integrity of the organization. Position Information: Department: Office of Compliance Salary Grade: 316 - $120,881 - $193,410 ($58.12 - $92.9856) Work Arrangement: Partial Telework This position is eligible for telework in California. Duties & Responsibilities: 45% - Leadership Functions Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department. Hires, manages, trains, supports, develops and evaluates direct reports. Directs work assignments, measures results and initiates personnel actions. Ensures that team members are trained and equipped with the necessary skills and resources. Collaborates with the director in departmental budgeting activities. Oversees the planning, scoping and execution of audits and the development of audit tools; ensures alignment with organizational goals and regulatory requirements. Oversees the planning, scoping and execution of investigations and the development of investigative tools; ensures alignment with organizational goals and regulatory requirements. Assists the director on development of the annual FWA risk assessment and Anti-Fraud, Waste and Abuse Plan. Assists department leadership in the management of critical business risks by communicating best practices, promoting process improvement, and monitoring remediation activities. 35% - Program Oversight Provides expertise and guidance to staff, management and other department areas on sensitive and complicated program integrity concerns, oversight and referrals. Creates and manages effective monitoring of ongoing investigations, including quality control, timeliness and business relations to continually evaluate FWA related activities. Performs reviews of investigations for sufficiency of content and documentation and escalates where appropriate. Prepares timely and accurate reporting on investigations, including scope, activities, methodologies, observations, deficiencies, recommendations and remediation activities. Presents investigative reports including findings, risks and recommendations to senior management. Collaborates with business areas to enhance systems, workflows and internal controls. Identifies benchmarking standards (leading practices) for identifying potential control gaps and/or opportunities for improving efficiency and compliance. Proposes recommendations for enhancing operational efficiency and identifying other areas of improvement. Provides excellent customer service by addressing concerns promptly and delivering actionable, professional insights. 15% - Investigative Activities Performs investigation activities for complex cases. Partners with staff in performing investigations of difficult cases. 5% - Other Completes other projects and duties as assigned. Minimum Qualifications: Bachelor's degree in business administration, accounting, health information management, or another related field PLUS 5 years of relevant work experience in health care investigations required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. 5 years of managerial experience within a managed care health plan in audits or investigations, or as an outside consultant engaged to perform audit work for a managed care health plan required. Have access to means of transportation for work away from the primary office approximately 15% of the time. Preferred Qualifications: Master's degree. Required Licensure / Certifications: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI) or similar certification completion, currently pursuing a related certification or has completed more than half of the requirements towards a certification. Knowledge & Abilities: Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. Work independently and exercise sound judgment. Communicate clearly and concisely, both orally and in writing. Work a flexible schedule; available to participate in evening and weekend events. Organize, be analytical, problem-solve and possess project management skills. Work in a fast-paced environment and in an efficient manner. Manage multiple projects and identify opportunities for internal and external collaboration. Motivate and lead multi-program teams and external committees/coalitions. Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Physical Requirements (With or Without Accommodations): Ability to visually read information from computer screens, forms and other printed materials and information. Ability to speak (enunciate) clearly in conversation and general communication. Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions. 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 10 to 25 pounds Work Environment: If located at the 500, 505 Building or a remote work location: Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. There are no harmful environmental conditions present for this job. The noise level in this work environment 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 present for this job. The noise level in this work environment is usually moderate to loud. If located in the Community: Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. Employee will occasionally work outdoors in varied temperatures. There may be harmful or hazardous environmental conditions present for this job. The noise level in this work environment is usually moderate to loud. About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 4