Role OverviewThe Investigator, Program Integrity supports the San Francisco Health Plan (SFHP) Compliance Program through fraud, waste, and abuse investigations, audits, and monitoring activities. 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.
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.
Why It Might Be a Fit
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.
Requirements
- Bachelor’s degree in business administration or a closely related field, or equivalent experience
- 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
Benefits
- Medical: choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP
- Dental: choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage
- Vision: Employee vision care coverage 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
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