Health Plan Oversight Auditor

Reporting to Director, Compliance & Oversight, the Health Plan Oversight Auditor supports San Francisco Health Plan's (SFHP) Compliance Program by performing assigned audit, monitoring, and investigative activities. You will execute defined audit procedures, analyzes documentation and data and prepares clear workpapers and reports under established methodologies and supervisory guidance. The Health Plan Auditor partners with internal teams to support regulatory compliance, identify control gaps, and contribute to corrective action efforts while building technical knowledge of managed care compliance and program integrity requirements.

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

WHAT YOU WILL DO:

• Perform assigned audits and monitoring reviews of internal departments, providers, vendors, and delegated entities in accordance with established audit plans, procedures, and timelines.
• Examines records, reports, workflows, and supporting documentation to assess compliance with applicable laws, regulations, contracts, and internal policies; identify potential control gaps and documents findings.
• Complete audit workpapers, testing documentation, and memoranda that reflect procedures performed, evidence reviewed, and conclusions reached.
• Helps develop and execute the Annual Audit Workplan by supporting planning activities, data collection, and issue tracking.
• Prepare draft audit reports, summaries, and management reports by collecting, analyzing, and synthesizing operational and compliance data.
• Communicate audit status and preliminary findings to the Director and designated stakeholders; participates in meetings to review results and clarify issues.
• Investigate leads generated by antifraud and monitoring systems; maintains assigned caseloads and prepares summary documentation for management review.
• Support monitoring of SFHP's policies and procedures and apply working knowledge of the policy development and approval process during audit activities.
• Assist in the development, documentation, and tracking of corrective action plans (CAPs); support follow-up testing to validate remediation.
• Coordinate administrative and logistical support for external audits and regulatory examinations, including document compilation and response tracking.
• Participate in the Program Integrity Workgroup and support development of the Annual Program Integrity Workplan and required regulatory reports.
• Conduct routine provider, vendor, and member reviews and investigations related to compliance, fraud, waste, abuse, and HIPAA concerns, escalating issues.
• Provide support to the Compliance Hotline by assisting with intake, research, and documentation of reported concerns.
• Monitor regulatory and industry developments and escalates potential compliance impacts to the Director.
• Maintain working knowledge of state and federal healthcare regulations and managed care requirements applicable to publicly funded programs.
• Contribute to departmental projects and process improvement initiatives; complete other responsibilities as assigned.

WHAT YOU WILL BRING:

• Bachelor's degree in business administration, healthcare administration, or a related field, or an equivalent of combined education or experience.
• Minimum of three (3) years of experience in healthcare operations, compliance, auditing, or program integrity.
• Knowledge of state healthcare programs, regulatory compliance, and antifraud activities.
• Professional certification such as Certified Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AFHI), Certified Internal Auditor (CIA), or healthcare compliance certification 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)

PI284152294