Shawn R. Hensley
Lincoln,CA
Summary
Experienced fraud and program integrity leader with extensive background in health coverage eligibility, fraud investigations, and risk management. Proven ability to build and lead anti-fraud functions, manage complex investigations, develop policies and procedures, and collaborate with regulators, law enforcement, and health plan partners. Strong track record in data-driven fraud detection, stakeholder coordination, and staff development in both public and private sector settings.
Overview
12
12
years of professional experience
Work History
Supervisor I – Program Integrity, Integrated Fraud Management (IFM) Team
Covered California – Program Integrity Division
10.2020 - Current
- Lead Covered California’s Integrated Fraud Management (IFM) anti-fraud function as a second line of defense for fraud prevention, detection, and reporting.
- Manage end-to-end fraud investigations, including intake, triage, evidence review, documentation in Salesforce/IFM logs, and case closure.
- Oversee high-risk fraud matters such as agent/broker fraud, Substance Use Disorder (SUD) facility schemes, and residency/income misrepresentation.
- Develop and maintain IFM policies, procedures, anti-fraud strategy, investigation guides, and referral guides aligned with GAO and CMS expectations.
- Conduct fraud risk assessment and analytics using dashboards and fraud personas to identify trends and refine rules and watchlists.
- Coordinate closely with internal partners (Service Center, OSD, Legal, Policy, Privacy, IT, Internal Audit) and external agencies (DHCS A&I, CDI, DMHC, DOJ, and law enforcement).
- Lead quarterly fraud collaboration meetings with QHP/QDP issuers to share fraud trends, introduce new IFM processes, and avoid duplicative/conflicting investigations.
- Design and deliver fraud-related training and quick-reference tools for staff and enrollers, oversee external fraud-related contracts to support IFM process improvements.
Health Program Specialist I – Program Integrity, Integrated Fraud Team
Covered California – Program Integrity Division
08.2018 - 10.2020
- Collaborated with risk committee teams, fraud team, service center operations, and other internal and external partners on fraud and risk matters.
- Monitored, reviewed, and edited fraud and risk management reports and materials for internal and external distribution.
- Served as a primary contributor in developing the Data Analytic Dashboard to support IFM fraud research and detection of fraud, waste, and abuse.
- Supported the Enterprise Risk Management team in preparing for monthly risk committee meetings, including materials and follow-up items.
- Assisted management with high-risk/high-profile projects affecting the Exchange and Covered California.
- Acted as a liaison for the manager, answering team questions, assisting with reports, and facilitating information flow.
- Monitored and prepared coordination of meetings with external agencies and created/monitored an Interagency Agreement with an external partner.
- Demonstrated strong written and verbal communication skills and facilitated monthly meetings.
Associate Governmental Program Analyst – Program Integrity, Integrated Fraud Team
Covered California – Program Integrity Division
11.2013 - 08.2018
- Performed analytical work supporting fraud, risk, and program integrity activities within the Integrated Fraud Team.
- Assisted in developing and updating fraud-related policies, procedures, and guidance documents.
- Supported production of reports, talking points, and presentations for management and external partners.
- Contributed to data collection, trend analysis, and case tracking to support fraud detection and prevention efforts.
Education
Bachelor of Science - Business Administration And Management
Sacramento State
Sacramento, CA06-1985
Skills
- Fraud, waste, and abuse (FWA) investigation and case management
- Health coverage eligibility, ACA, and program integrity
- Risk assessment, data analytics, dashboards, and fraud personas
- Policy, procedures, and investigation/referral guide development
- Interagency coordination (DHCS A&I, CDI, DMHC, DOJ, law enforcement)
- Stakeholder engagement with QHP/QDP issuers and internal divisions
- Training, job aids, and quick-reference tools
- Staff supervision, coaching, and performance management
- Report writing, presentations, and executive briefings
Timeline
Supervisor I – Program Integrity, Integrated Fraud Management (IFM) Team
Covered California – Program Integrity Division
10.2020 - Current
Health Program Specialist I – Program Integrity, Integrated Fraud Team
Covered California – Program Integrity Division
08.2018 - 10.2020
Associate Governmental Program Analyst – Program Integrity, Integrated Fraud Team
Covered California – Program Integrity Division
11.2013 - 08.2018
Bachelor of Science - Business Administration And Management
Sacramento State
Additional Information
- Strong written and verbal communication skills; experienced in drafting reports, job aids, and training materials.
- Extensive experience facilitating meetings with internal leadership, external agencies, and health plan partners.