Location: San Francisco, CA
Are your ready to make a difference in managed healthcare for the vulnerable communities of San Francisco?
Under the general direction of the Manager, Compliance and Oversight, the Audit Analyst is responsible for supporting the San Francisco Health Plan (SFHP) Compliance Program through audit and monitoring activities. Responsibilities include:
- Auditing and monitoring external provider and vendor entities
- Auditing and monitoring various internal department processes
- Developing audit tools, audit reports, and criteria metrics
- Communicating effectively and efficiently with internal and external clients regarding auditing and monitoring activities.
The ideal candidate will bring excellent healthcare audit experience to translate complex issues into actionable plans with deliverables and measurable outcomes. The candidate must be able to work independently and collaborate with various teams and organizations to deliver multiple complex projects within the Compliance Team.
WHAT YOU WILL DO:
- Ensures compliance with regulations and controls by examining and analyzing records, reports, operating practices, and documentation; recommending opportunities to strengthen the internal control structure.
- Assists the Manager, Compliance and Oversight in development and implementation of Annual Audit Workplan.
- Completes audit work papers and memorandums by documenting audit tests and findings.
- Communicates audit progress and findings by preparing reports; presenting information in various formats, including in-person meetings.
- Prepares special audit and control reports by collecting, analyzing, and summarizing operating information and trends.
- Provides management reports by collecting, analyzing, and summarizing management information.
- Investigates leads generated by anti-fraud software platform, maintain caseload and provide summary reports to management.
- Enhances compliance department and organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
- Assists in the monitoring of SFHP’s policies and procedures with strong working knowledge of policy development and approval process.
- Consults in the development and monitoring of corrective action plans to mitigate risks.
- Regularly schedules and attends meetings with management to communicate audit findings, discuss identified risks, and explore suitable solutions.
- Assists with the coordination of external audits, providing documentation, and other administrative support.
- Supports and participates in the SFHP Program Integrity Workgroup.
- Conducts routine and focused provider and member investigations.
- Supports and participates in the development of the Annual Program Integrity Workplan and regulatory reports.
- Trains and assists various departments in developing best practices in their operations in accordance with established policies and procedures.
- Provides 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.
- Monitors regulatory, industry, and compliance climate and escalate issues when necessary.
- Maintains a strong working knowledge of state and federal legislation, statutes and regulations, and local, state, and national health issues affecting publicly-funded managed care organizations.
WHAT YOU WILL BRING:
- Bachelor’s degree in business administration or closely 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) required.
- Minimum 5 years of experience in health care industry and operations
- Specialized knowledge in state programs, regulatory compliance and antifraud activities required; with the ability to analyze and interpret legislative, statutory, regulatory, and legal language
- Certification in health care compliance preferred.
- Experience in coordinating and providing support to large complex projects
- Excellent communication skills required, including editing and proofreading skills
- Excellent logic, planning and problem-solving skills
- Ability to analyze varying and large amounts of data to extrapolate meaning and use; detect and report on findings and trends, and support conclusions and recommendations using valid sources of data
- Ability and willingness to take initiative to address problems and make continuous process improvements
- Ability to interface with all levels of staff and management
- Advanced level proficiency with MS Office applications
San Francisco Health Plan (SFHP) is a 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. San Francisco Health Plan is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 140,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.
San Francisco Health Plan is an Equal Opportunity Employer (EOE) M/F/D/V
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.