Health Plan Audit Analyst

Reporting to the Director, Compliance and Oversight, the Health Plan Audit Analyst supports the San Francisco Health Plan (SFHP) Compliance Program through audit and monitoring activities. You will audit and monitor external provider and vendor entities and internal department processes. You will also develop audit tools, audit reports, and criteria metrics and also communicate with internal and external stakeholders on the status of auditing activities.

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: $78,875 - $91,635 per year

WHAT YOU WILL DO:

• Ensure compliance with regulations and controls by examining and analyzing records, reports, operating practices, and documentation; recommend opportunities to strengthen the internal control structure.
• Assist the Director, Compliance and Oversight, in development and implementation of Annual Program Integrity Workplan.
• Complete audit work papers and memorandums by documenting audit tests and findings.
• Communicate audit progress and findings by preparing reports; present information in various formats, including in-person meetings.
• Prepare special audit and control reports by collecting, analyzing, and summarizing operating information and trends.
• Provide management reports by collecting, analyzing, and summarizing management information.
• Help investigate leads generated by anti-fraud software platform, maintain case and provide summary reports to management.
• Enhance compliance department and organization reputation by accepting ownership for accomplishing new and different requests; explore opportunities to add value to job accomplishments.
• Help monitor SFHP's policies and procedures with working knowledge of policy development and approval process.
• Consult in the development and monitoring of corrective action plans to mitigate risks.
• Schedule and attend meetings with management to communicate audit findings, discuss identified risks, and explore suitable solutions.
• Help coordinate external audits, providing documentation, and other administrative support.
• Support and participate in the SFHP Program Integrity Workgroup.
• Conduct routine and focused provider and member audits.
• Support and participate in the progress tracking of the Annual Program Integrity Workplan and regulatory reports.
• Train and assist various departments in developing best practices in their operations in accordance with established policies and procedures.
• Provide support to the Compliance hotline and support the investigation and research of allegations of HIPAA violations, fraud waste and abuse, and other compliance issues.
• Monitor regulatory, industry, and compliance climate and escalate issues.
• Maintain a working knowledge of state and federal legislation, statutes and regulations, and local, state, and national health issues affecting publicly-funded managed care organizations.
• Maintain knowledge of business products and related SFHP policies and procedures.

WHAT YOU WILL BRING:

• Bachelors Degree in business administration or 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).
• A minimum of five (5) years of experience in Medicare and Medicaid health care plan industry and operations
• Specialized knowledge in state programs, regulatory compliance and antifraud activities, required.
• Certification in health care compliance 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)