Established in 1997, 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. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 145,000+ 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.
Under the general direction of the Manager of Delegate Oversight, the Oversight Audit Specialist supports the Oversight Audit Program and is responsible for the execution of audit work plan of designated SFHP’s delegated groups.
WHAT YOU’LL DO
- Support Manager in oversight of delegates categorized as HEALTH PLANS and OTHERS.
- Apply self-leadership skills to secure achievement of organizational goals.
- Execute Annual Oversight Audit Work Plan for assigned delegates.
- Coordinate oversight efforts with all delegated entities to ensure compliance with state, federal, and NCQA requirements.
- Prepare audit materials and attend audit readiness sessions.
- In collaboration with sister plans, support audit team comprised of SFHP SMEs to execute audit and monitoring activities.
- Analyze audit results and draft Audit Reports.
- Monitor Corrective Action Plans (CAPs); report instances of non-compliance as required.
- Participate in the review and update of Audit Tools.
- Performs and/or assists with certain non-clinical audits.
- Work collaboratively with internal customers to design and implement strategies to increase delegates’ engagement in driving toward quality outcomes.
- Assist with delegated groups and internal business owner relationships to ensure compliance, optimal delegate performance, and achievement of business goals according to service level and other contractual requirements.
- Analyze procedures and processes to continually improve delegation and oversight operations; provide recommendations to Manager.
- Present audit results to PNOC.
- Assist with the review of department policies, desktop procedures, and other documents.
- Monitor the general performance of delegated groups to meet compliance with requirements and delegated functions.
- Maintains Delegation Oversight readiness for DHCS audits, DMHC regulatory surveys, and NCQA accreditation (prepare reports/documents; assist with onsite reviews and post-survey follow-up activities).
- Coordinate activities with all levels of staff as well as with delegated and potentially delegated external entities through clear and concise verbal and written communication.
- Identify complex and sensitive project and team issues, and escalate as needed.
- Stay informed about the latest developments in delegate oversight fields, including new products and services, through relevant subject matter resources, professional associations, industry conferences, training seminars, and other information sources.
- Represents Delegation and Oversight Department at internal cross-functional meetings as needed.
- Represents SFHP at external meetings as needed.
WHAT YOU’LL BRING
- BA/BS in Business Administration, Compliance, Social Sciences, or related field required.
- Two years of audit, compliance, or health care audit experience
- Knowledge of managed care and Medi-Cal and other state-sponsored health programs strongly preferred
- Knowledge of health care compliance in managed care systems or provider organizations
- Experience with writing audit reports and taking meeting minutes
- Experience with presentations and leading diverse groups
- Ability to communicate effectively (spoken and written) with a variety of professionals, including physicians and other health providers, administrators and others.
- Detail-oriented and organized with the ability to interpret policy and make decisions.
- Versatility, flexibility, and professionalism
- Demonstrated ability to learn quickly
- Ability to work with multiple departments within the organization and external clients
- Demonstrated working ability using a total managed care system
- Strong MS Office skills: Outlook, Word, Excel, and PowerPoint
- Experienced with electronic file management, SharePoint preferred
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.