Program Integrity Specialist II (Defined Term)

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 Proficiency with Windows-based PC systems and Microsoft Word, Outlook, PowerPoint and Excel (including pivot tables), and Adobe Acrobat Knowledge of research, analysis, and reporting methods Knowledge of general health care compliance and privacy principles, quality improvement practices, and related audit techniques 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 Ability to conduct thorough investigations and produce well-documented and accurate conclusions and recommendations Ability to develop, implement, and monitor corrective action plans with guidance Ability to understand and interpret provider contracts and provider payment system processes Ability to identify and research relevant legal materials, analyze and interpret legal and contractual language Knowledge of HIPAA regulations Experience working remotely and ability to self-motivate Excellent multitasking skills Knowledge of the Medi-Cal and Medicare Advantage programs and related regulations

Conducts medium- to high-complexity investigations into alleged fraud, waste and abuse (FWA) 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