Investigator, Compliance Program Integrity

$80,000 - $97,000/Yr

San Francisco Health Plan - San Francisco, CA

Full-time - Mid Level

Hybrid - San Francisco, CA

Administration of Human Resource Programs

About the position

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. 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.

Responsibilities

• 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.
• 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.

Requirements

• 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.

Nice-to-haves

• Certification in health care compliance preferred.

Benefits

• Health Benefits
• Medical: Youll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
• Dental: Youll 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.