Healthcare Compliance Investigator - Program Integrity

Sfhp; San Francisco (CA); Hybrid; USD 100,000 - 115,000; Full time

Benefits offered by this job

Medical plans

Dental plan

Vision care

Retirement plans

PTO & holidays

Professional development

Job summary

San Francisco Health Plan (SFHP) is seeking an Investigator, Program Integrity to lead objective investigations, audits, and monitoring activities. You will manage a caseload, synthesize evidence into professional reports, and communicate findings to management and external partners.

The role requires rigorous data analysis and cross-functional collaboration, with a hybrid onsite-work arrangement in Downtown San Francisco. The position reports to the Director, Compliance and Oversight.

Qualifications

• Bachelor’s degree in business administration or closely related field, or equivalent experience required.
• Minimum of five (5) years of experience in the healthcare industry and healthcare operations.
• Certification as CPC, AHFI, or CIA preferred.

Responsibilities

• Conduct investigations into fraud, waste, or abuse, including provider and member investigations, audits, and monitoring events.
• Manage a caseload of internal and external leads and provide summary reports to management.
• Review evidence and synthesize data into professional investigative reports with findings and recommendations.
• Document investigative steps and findings in reports and memorandums.
• Communicate progress and findings through reports and in-person meetings.
• Examine records to ensure compliance with regulations and strengthen internal controls.
• Prepare special audit and management reports by analyzing operating information and trends.
• Assist in developing the Annual Program Integrity Workplan and Medicare D-SNP framework.
• Support the SFHP Program Integrity Workgroup and monitor corrective action plans.

Skills

Healthcare experience

Regulatory compliance

Investigation skills

Data analysis

Education

Bachelor’s degree in business administration or related field

Job description

San Francisco Health Plan (SFHP) is seeking an Investigator, Program Integrity to lead objective investigations, audits, and monitoring activities. You will manage a caseload, synthesize evidence into professional reports, and communicate findings to management and external partners.

The role requires rigorous data analysis and cross-functional collaboration, with a hybrid onsite-work arrangement in Downtown San Francisco. The position reports to the Director, Compliance and Oversight.