Sr Manager, Fraud, Waste and Abuse (Investigations) (Sr Manager I)
CalOptima
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:
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 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the 2025 CalOptima Health Benefits Guide regarding our comprehensive benefits and wellness package.
IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS
Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is June 30, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.
The selection process may include, but is not limited to, a skills assessment, phone screen and interview.
The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.
Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.
CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.
CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.
To apply, please visit: https://jobs.caloptima.org/jobs/sr-manager-fraud-waste-and-abuse-investigations-sr-manager-i-505-city-parkway-west-california-united-states
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