Compliance Investigator

The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Compliance Investigator to conduct and report investigations of potential non-compliance issues including Fraud, Waste and Abuse (FWA) and HIPAA non-compliance.

The essential duties and responsibilities will include the following: 

• Receive allegations/concerns from internal and external sources and conduct investigations into non-compliance.
• Prepare and submit summary reports including recommendations for improvement.
• Ensure that all investigations are conducted in a timely and confidential manner, and all findings are maintained as such.
• Assist the Management in the development and implementation of corrective action plans. Collaborate with Compliance department staff on corrective actions as necessary.
• Utilize FWA detection software in identifying potential FWA issues by tracking trends in claims accuracy, coding, and billing behaviors.
• Identify possible areas of risk based on the trending and provide recommendations to Chief Compliance Officer to address the issues.
• Prepare trending reports on non-compliance.

Requirements:

Education and Experience: Bachelor’s Degree in Healthcare, Health Administration, Business Administration or related discipline. Related and relevant experience may be considered in lieu of academic requirements on a year for year basis. Three (3) years of experience in healthcare or similar operational area. Managed care background preferred.

Knowledge of: Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint. Familiarity with the health care field. Regulatory and or compliance processes impacting managed health care. Principles and methods of planning, directing and maintaining compliance with regulatory standards. Principles and practices of managed care health care systems, medical administration and NCQA accreditation standards.

Ability to: Work cooperatively with others. Work as part of a team and support team decisions. Communicate effectively, both verbally and in writing. Adapt to changes in requirements/priorities for daily and specialized tasks.

Starting Compensation Range: - Depending on Experience

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage.  Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits.  Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.