Investigator, Program Integrity

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

Benefits offered by this job

Health benefits

CalPERS Pension/401(a) plans

Paid time off

Professional development

Job summary

San Francisco Health Plan in San Francisco, CA is seeking an Investigator, Program Integrity to support the Compliance Program through fraud, waste, and abuse investigations, audits, and monitoring activities. You will independently manage a caseload and produce professional reports with findings and recommendations.

This hybrid role requires onsite presence in Downtown San Francisco at least 4 days per month.

Qualifications

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

Responsibilities

• Conduct objective, fair, thorough 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 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.
• Examine and analyze records, reports, operating practices, and documentation to ensure compliance and strengthen controls.
• Prepare special audit, control, and management reports by collecting, analyzing, and summarizing data.
• Assist the Director, Compliance & Oversight in developing and implementing the Annual Program Integrity Workplan.
• Assist in developing the Medicare D-SNP Program Integrity framework.
• Support and participate in the SFHP Program Integrity Workgroup.
• Consult in developing and monitoring corrective action plans to mitigate identified risks.
• Schedule and attend meetings with management to discuss findings and risks.
• Assist with coordination of external audits and provide documentation support.
• Provide support to the Compliance hotline and investigate HIPAA violations and other issues.
• Train departments in operational best practices per policies and procedures.

Skills

Investigations

Data analysis

Regulatory compliance

Report writing

Communication

Education

Bachelor’s degree in business administration or closely related field

Job description

Investigator, Program Integrity

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 escape 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.

ABOUT SFHP:

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

(Hybrid remote/in-office)

Equal employment opportunity, including veterans and individuals with disabilities.

PI287389791