Program Integrity Investigator — Hybrid (San Francisco)

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

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.