Senior Fraud, Waste, and Abuse Specialist – SHP Member Services – Day Shift – Full Time

Facility: Health Plan

City San Diego

Department

Job Status

Regular

Shift

Day

FTE

1

Shift Start Time

Shift End Time

Bachelors Degree; Certified in Healthcare Compliance (CHC) – Health Care Compliance Association (HCCA)

Hours :

Shift Start Time:

Variable

Shift End Time:

Variable

AWS Hours Requirement:

8/40 – 8 Hour Shift

Additional Shift Information:

Any full-time schedule between 7am and 6pm, Monday – Friday.

Weekend Requirements:

No Weekends

On-Call Required:

No

Hourly Pay Range (Minimum – Midpoint – Maximum):

$46.957 – $60.590 – $74.223

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do

The Senior Fraud, Waste and Abuse Specialist at Sharp Health Plan is a critical role responsible for overseeing the entire lifecycle of fraud, waste, and abuse (FWA) investigations. This position involves triaging allegations, conducting thorough investigations, analyzing data for irregular patterns, and ensuring compliance with regulatory, accreditation and contract standards. The Senior FWA Specialist will manage day-to-day anti-fraud activities, coordinate with the Anti-Fraud Committee, and provide essential training and resources to team members. This role requires a proactive approach to prevent and detect fraudulent activities within the managed care environment and requires someone with a keen eye for detail and a strong understanding of health plan regulations.

Required Qualifications

Bachelors Degree in healthcare administration, criminal justice, finance, business or related field.

5 Years in healthcare fraud investigation, preferably in a health plan, health insurance or managed care setting.

Preferred Qualifications

1 Year experience leading cross-functional teams and projects.

Certified in Healthcare Compliance (CHC) – Health Care Compliance Association (HCCA) -PREFERRED

Other Qualification Requirements

Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) Certification – Preferred

Essential Functions

Intake, Triage and CaseworkEvaluates all incoming reports of potential FWA to determine their credibility and urgency. Prioritizes cases based on severity and potential impact to the organization.Initiates preliminary investigations to gather sufficient information for case progression. Conducts casework from initiation to resolution, ensuring thorough investigation and documentation. Conducts comprehensive investigations into each case of suspected FWA.Coordinates with internal and external stakeholders to collect evidence and testimonies. Collaborates with relevant departments to ensure a seamless flow of information and resources.Analyzes all gathered information to identify fraudulent patterns and substantiate claims.Ensures thorough documentation of investigative processes and findings to support legal and regulatory requirements.Concludes investigations with actionable recommendations for education, recoveries, reporting, and/or improved organizational controls.Reports verified findings to applicable legal and regulatory bodies.Collaborates with Sharp Legal Services on complex cases.

Data AnalysisPerforms data analysis to identify trends and patterns related to FWA.In partnership with data analytics team(s), utilizes data analytics tools to scrutinize large datasets for anomalies and suspicious activities.Interprets analytical results to uncover underlying trends and potential areas of risk.Reviews HealthCare Fraud Prevention Partnership (HFPP) findings and makes recommendations to Anti-Fraud Committee for follow-up.Develops reports summarizing findings and presents them to management and the Anti-Fraud Committee. Utilizes findings to make recommendations for annual workplan.Stays informed about new analytical techniques and technologies to continuously refine the analysis process.

Oversight of Delegate FWA ActivitiesOversees delegate FWA activities, provides feedback, and reports findings to the Anti-Fraud Committee.Monitors the performance of delegated entities to ensure compliance with FWA policies.Compiles annual report detailing delegate activities and presents to the Anti-Fraud Committee.Works with delegates and applicable Plan departments to implement recommended corrective actions and follow-up measures to uphold the integrity of delegated functions.

Anti-Fraud CommitteePrepares agendas, materials, and minutes for Anti-Fraud Committee meetings and facilitates discussions.Presents results of case investigations.Distributes information on research, trends, and educational resources to Committee members to enhance their knowledge.

Regulatory ComplianceConducts assessment of SHP FWA risks and recommends priority areas of focus.Develops annual FWA workplan in collaboration with the Anti-Fraud Committee, outlining key objectives and strategies.Reviews and revises the workplan to incorporate new regulatory requirements, organizational changes, fraud risks, and best practices.Ensures that all FWA activities align with the workplan and meet regulatory and contractual compliance standards.Prepares required plans and reports for submission to regulators and key partners in a timely and accurate manner.Collaborates with SHP’s Compliance Department to implement strategies to foster a culture of compliance and awareness within SHP. Actively supports external audits of FWA functions.

Professional DevelopmentAdheres to personal plan of professional development and growth through professional affiliations, activities and continuing education.Maintains current credentials in FWA and knowledge of federal and state regulations, policies and procedures related to FWA.Participates in industry workgroups and conferences to stay abreast of the latest trends in fraud, waste, and abuse. Applies learning to work products such as risk assessment and annual workplan.

Knowledge, Skills, and Abilities

Strong understanding of healthcare laws, regulations, and accreditation standards related to fraud, waste, and abuse.

Proficiency in data analysis and experience with fraud investigative tools and techniques.

Computer proficiency with Microsoft Office applications required.

Self-starter who is eager to learn and can work independently and in a team environment. Ability to function within a fast-paced, dynamic, and growing environment.

Strong analytical, organizational, and professional skills.

Excellent time management and problem-solving skills.

Team-oriented with strong interpersonal and communication skills.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class