San Francisco Health Plan · 8 hours ago
Health Plan Audit Analyst
San Francisco, CA
Full-time
Hybrid
Mid, Senior Level
$79K/yr - $92K/yr
5+ years expSan Francisco Health Plan (SFHP) is an award-winning managed care health plan committed to providing affordable health care coverage to underserved residents. The Health Plan Audit Analyst supports the Compliance Program through auditing and monitoring activities, developing audit tools, and communicating with stakeholders.
Health Care
Responsibilities
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
Qualification
Required
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
Preferred
Certification in health care compliance preferred
Benefits
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.
Company
San Francisco Health Plan
San Francisco Health Plan is a community health plan that provides affordable & high-quality health care coverage for San Franciscans.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
John F. Grgurina Jr.
CEO
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