Compliance Analyst

Job Description

Responsibilities

Job Summary :

The provides support to the organization to execute key initiatives for the effectiveness of the Compliance Program for health plan products, including Medicare Parts C and D, large- and small-group health plans, third-party administration, and other commercial health plan products.

The Compliance Analyst captures and analyzes data used to detect trends that may indicate systemic risks to the organization requiring further review, assessment, root cause analysis, or follow-up.

The Compliance Analyst will support the Compliance Program to ensure compliance with Federal and State laws and regulations contract provisions, accreditation standards, and internal policies and procedures.

Job Duties :

• Ensures Completion of Compliance Training by Prominence Health Plan Employees
• Ensures Completion of Compliance Training by Agents / Brokers
• Manages and Distributes HPMS and Agency Communications
• Authors Operational Audit Reports
• Authors and Facilitates Implementation of Operational Corrective Action Plans
• Performs Operational Audits
• Maintains Masterfile of Operational Risk Areas
• Performs / Facilitates External Compliance Audits
• Performs / Facilitates External Financial Audits (1 / 3 Financial, Bid Audit, Program Audit, etc.)
• Performs / Facilitates OIG / GSA Exclusion Screening (Prominence Health Plan Staff-FT / PT, Volunteers, Interns, Board Members, Providers)
• Operational Incident Management Resolution
• Performs / Facilitates Operational Corrective Action Plan Resolution and Monitoring
• Performs Operational Risk Assessment
• Performs Compliance Program Effectiveness Risk Assessment
• Coordinates Compliance and Department Meetings

Qualifications

Qualifications and Requirements :

• Bachelor’s degree or equivalent work experience.
• Minimum two years’ experience in health insurance or health care compliance; experience with managed care organizations and Medicare Advantage preferred.
• Experience with State and Federal laws, regulations, policies and practices for the administration of Medicare Advantage, Prescription Drug Plan, and managed care organizations.
• Demonstrated ability to effectively communicate in English, both verbally and in writing.
• General knowledge of health insurance, managed care, benefit design, and various state and federal regulations.
• Proficient computer skills : Health Plan Management System (HPMS), Smartsheet, Sharepoint, Microsoft Office (Word, Excel, PowerPoint), and database software.
• Knowledge of Medicare programs and CMS regulations and the ability to provide operational guidance and support for defining and documenting data validation policies and procedures, requirements for technical specifications, and data reporting skills to support specified components of Medicare Part C & Part D programs.
• Knowledge of Compliance Program principles to include analyzing risk assessments, performing audits, creating reports, educating and following up with the business area to ensure processes exist to demonstrate compliance with Federal and State requirements.
• Demonstrated ability to apply knowledge to recognize the existence of problems or potential problems and identify additional research to be undertaken or assistance in the following areas : internal audit standards, procedures and techniques, management principles and deviations from ethical business practices, and fundamentals of business management.
• Demonstrated ability to research, analyze and interpret state / federal regulations related to health insurance and healthcare.
• Demonstrated ability to design and develop reports, documents and spreadsheets.
• Demonstrated ability to communicate verbally and with technical writing in a way that effectively conveys project background, objectives, activities, evaluations, conclusions, and recommendations.
• Decisive and exercises good judgment under pressure.
• Demonstrated skills in critical thinking, problem solving, and the analysis, interpretation and evaluation of complex information.
• Demonstrated ability to maintain effective collaborative working relationships with staff.
• Demonstrated ability to work independently with minimal supervision.
• Resourceful, detail-oriented, and able to assimilate and analyze a wide variety of information, often working under deadline pressure with a variety of levels of staff.
• Simultaneous action at varying stages initiation, follow through, and completion on a number of different projects.
• Strict adherence of rules and regulations for confidentiality and compliance.
30+ days ago