Program Integrity Specialist

Summary

Join the Central California Alliance for Health as a Program Integrity Specialist II in the Compliance Department. This role involves conducting investigations into alleged fraud, waste, and abuse, assisting with program integrity activities, and supporting privacy-related compliance. The ideal candidate has experience in managed care or healthcare, knowledge of HIPAA regulations, and proficiency in Microsoft Office. The position requires a Bachelor’s degree and three years of relevant experience or an equivalent combination. The Alliance offers a hybrid work environment and a comprehensive benefits package.

Requirements

• Has experience working 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
• Understand and interpret provider contracts and provider payment system processes
• Identify and research relevant legal materials, analyze and interpret legal and contractual language
• Education and Experience: Bachelor’s degree in Healthcare Administration, Public Health Administration, Criminal Justice, Finance, or a related field and a minimum of three years of program integrity, auditing, quality improvement, or compliance-related experience in the healthcare industry (a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

Responsibilities

• 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

Benefits

• Medical, Dental and Vision Plans
• Ample Paid Time Off
• 12 Paid Holidays per year
• 401(a) Retirement Plan
• 457 Deferred Compensation Plan
• Robust Health and Wellness Program
• Onsite EV Charging Stations