Reporting to the Director, Compliance and Oversight, the Investigator, Program Integrity supports the San Francisco Health Plan (SFHP) Compliance Program through fraud, waste, and abuse investigations, audits, and monitoring activities. The Investigator independently manages and prioritizes a caseload of internally and externally generated leads, conducting objective, fair, thorough, and timely investigations and synthesizing evidence into professional reports with findings and recommendations.
The role conducts routine and focused provider and member audits and monitoring events, supports the coordination of external audits, and contributes to the Annual Program Integrity Workplan and the Medicare D-SNP Program Integrity framework. This work requires sound judgement, rigorous data analysis, and clear communication with staff, management, and external partners to strengthen SFHP's internal control structure and mitigate compliance risk.
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: $100,000 - $115,000 per year
WHAT YOU WILL DO: - Conduct objective, fair, thorough, unbiased, and timely investigations into allegations of fraud, waste, or abuse, including routine and focused provider and member investigations, audits, and other monitoring events.
- Manage and prioritize a caseload of internally and externally generated leads, and provide summary reports to management.
- Review and research evidence to analyze the overall fact pattern of a case and synthesize data into professional reports with recommendations.
- Document investigative steps and findings in investigative reports and memorandums.
- Communicate investigative progress and findings by preparing reports and presenting information in various formats, including in-person meetings.
- Examine and analyze records, reports, operating practices, and documentation to ensure compliance with regulations and controls, and recommend opportunities to strengthen the internal control structure.
- Prepare special audit, control, and management reports by collecting, analyzing, and summarizing operating information and trends.
- Assist the Director, Compliance & Oversight in the development and implementation of the Annual Program Integrity Workplan.
- Assist in the development of the Medicare D-SNP Program Integrity framework.
- Support and participate in the SFHP Program Integrity Workgroup.
- Consult in the development and monitoring of corrective action plans to mitigate identified risks.
- Schedule and attend meetings with management to communicate audit findings, discuss identified risks, and explore suitable solutions.
- Assist with the coordination of external audits, including providing documentation and administrative support.
- Provide support to the Compliance hotline, and assist in the investigation and research of allegations of HIPAA violations, fraud, waste, and abuse and other compliance issues.
- Train and assist departments in developing operational best practices in accordance with established policies and procedures.
- Monitor the regulatory, industry, and compliance climate, and escalate issues when necessary.
WHAT YOU WILL BRING: - Bachelor's degree in business administration or a closely related field, or equivalent experience required.
- Minimum of five (5) years of experience in the healthcare industry and healthcare operations.
- Certification as a Certified Professional Coder (CPC), Accredited Health Care Fraud Investigator (AHFI), or Certified Internal Auditor (CIA) 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, professional license/membership.
#LI-Hybrid
(Hybrid remote/in-office)
