Investigator, Compliance Program Integrity

Under the general direction of the Director, Compliance and Oversight, you will support the San Francisco Health Plan (SFHP) Compliance Program through audit, investigation, and monitoring activities.

Responsibilities include :

• Conducting objective, fair, detailed and unbiased investigations into allegations of fraud, waste or abuse.
• Reviewing and researching evidence to analyze the fact patterns of claims and summarize data into a professional report with recommendations.
• Managing a large caseload to achieve positive results.
• Communicating with internal and external clients regarding auditing and monitoring activities.

SFHP is proud to support a hybrid work environment - as such, you will be required to be onsite and in-office a minimum of 4 days per month.

Salary : $80,000 - $97,000

WHAT YOU WILL DO

• Ensure compliance with regulations and controls by examining and analyzing records, reports, operating practices, and recommending opportunities to strengthen the internal control structures.
• Complete investigative reports and memorandums by documenting investigative steps and findings.
• Prepares special audit and control reports by collecting, analyzing, and summarizing operating information and trends.
• Provides management reports by collecting, analyzing, and summarizing management information.
• Investigate leads generated internally and externally, maintain a caseload, and provide summary reports.
• Develop the Medicare D-SNP Program Integrity framework.
• Conduct routine and focused provider and member investigations, audits, and other monitoring events.
• Provide support to the Compliance hotline and assist in the investigation and research of allegations of HIPAA violations, fraud waste and abuse violations, and other compliance issues.
• Maintain a strong working knowledge of state and federal legislation, statutes and regulations, and local, state, and national health issues affecting publicly funded managed care organizations.

WHAT YOU WILL BRING

• Bachelors Degree in business administration or closely related field, or equivalent experience.
• Certified in one of three (3) areas : Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AFHI), or Certified Internal Auditor (CIA).
• Five (5) or more years of experience in health care and operations
• Specialized knowledge in program integrity, state programs, Medicare and Medicaid programs, regulatory compliance and antifraud activities.
• Certification in health care compliance preferred.

WHAT WE OFFER

• Health Benefits
• Medical : You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
• Dental : You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
• Vision : Employee vision care coverage is available through Vision Service Plan (VSP).
• Retirement - Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off - 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development - Opportunities for tuition reimbursement and professional license / membership.

ABOUT US

Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County.

SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.

San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

San Francisco Health Plan is an E-Verify participating employer.

Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.

LI-Hybrid

Please see job description

PI248498111