Health Plan Audit Analyst

SF Health Plan • San Francisco, CA

78d • Hybrid

About The Position

Reporting to the Director, Compliance and Oversight, the Health Plan Audit Analyst supports the San Francisco Health Plan (SFHP) Compliance Program through audit and monitoring activities. You will audit and monitor external provider and vendor entities and internal department processes. You will also develop audit tools, audit reports, and criteria metrics and also communicate with internal and external stakeholders on the status of auditing activities. Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office. Salary: $78,875 - $91,635 per year

Requirements

• Bachelors Degree in business administration or 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).
• A minimum of five (5) years of experience in Medicare and Medicaid health care plan industry and operations
• Specialized knowledge in state programs, regulatory compliance and antifraud activities, required.

Nice To Haves

• Certification in health care compliance preferred.

Responsibilities

• Ensure compliance with regulations and controls by examining and analyzing records, reports, operating practices, and documentation; recommend opportunities to strengthen the internal control structure.
• Assist the Director, Compliance and Oversight, in development and implementation of Annual Program Integrity Workplan.
• Complete audit work papers and memorandums by documenting audit tests and findings.
• Communicate audit progress and findings by preparing reports; present information in various formats, including in-person meetings.
• Prepare special audit and control reports by collecting, analyzing, and summarizing operating information and trends.
• Provide management reports by collecting, analyzing, and summarizing management information.
• Help investigate leads generated by anti-fraud software platform, maintain case and provide summary reports to management.
• Enhance compliance department and organization reputation by accepting ownership for accomplishing new and different requests; explore opportunities to add value to job accomplishments.
• Help monitor SFHP's policies and procedures with working knowledge of policy development and approval process.
• Consult in the development and monitoring of corrective action plans to mitigate risks.
• Schedule and attend meetings with management to communicate audit findings, discuss identified risks, and explore suitable solutions.
• Help coordinate external audits, providing documentation, and other administrative support.
• Support and participate in the SFHP Program Integrity Workgroup.
• Conduct routine and focused provider and member audits.
• Support and participate in the progress tracking of the Annual Program Integrity Workplan and regulatory reports.
• Train and assist various departments in developing best practices in their operations in accordance with established policies and procedures.
• Provide support to the Compliance hotline and support the investigation and research of allegations of HIPAA violations, fraud waste and abuse, and other compliance issues.
• Monitor regulatory, industry, and compliance climate and escalate issues.
• Maintain a working knowledge of state and federal legislation, statutes and regulations, and local, state, and national health issues affecting publicly-funded managed care organizations.
• Maintain knowledge of business products and related SFHP policies and procedures.

Benefits

• 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, professional license/membership.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 251-500 employees