Compliance Analyst

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Compliance Analyst
The candidate will assist in maintaining an internal compliance program; guide special projects; provide regulatory interpretation; perform compliance reporting; and develop and implement compliance auditing and monitoring strategies. Is responsible for conducting audits of departments involved in the delivery or administration of Medicare Advantage and Medicare Part D plans for compliance with CMS and company standards, including: Part C & Part D program compliance, state laws and regulatory compliance, privacy and security, detecting, preventing, and correcting fraud, waste, and abuse. Create and maintain databases and spreadsheets related to regulatory submissions and reporting, licensing, contracts, policies, procedures, laws and regulations. Understand and prioritize timeframes associated with CMS Medicare Advantage (MA) Prescription Drug (PD), federal and state regulatory submissions/reporting calendar, AHP Compliance Toll-Free Hotline, CMS Complaint Tracking Module (CTM) and other documents. Communicate state and federal requirements to internal and external clients. Review and monitor new and updated laws and regulations, disseminating findings to key stakeholders accordingly. Participate on various compliance subcommittees and workgroups. Perform periodic compliance audits, risk assessments and conducts related ongoing compliance monitoring activities. Prepare analyses/reports based on audit results, including recommendations for corrective action; maintain records of audits and follow-up of corrective actions. Assist management in developing compliance audit instruments and protocols. Under leadership’s guidance, communicate with regulatory agencies to clarify requirements, address reporting and filing issues. Respond to external requests for information required by the organization for its regulatory filings; respond to inquiries from state and federal regulatory agencies. Assist in developing, producing and conducting compliance training programs. Assist affiliated and managed health plans in managing relationships with regulatory agencies and seek to resolve policy issues which may negatively impact service to members. Working knowledge of related federal and state laws and regulations and CMS compliance. Ability to demonstrate strong understanding of CMS requirements and regulations related to Medicare Advantage and Medicare Part D operations and compliance. Ability to effectively present highly complex information and respond to questions from groups of managers, clients, customers, and the public. 3+ years’ related experience in compliance, privacy and/or regulatory affairs, legal assistant/paralegal. Experience in health care industry in related field including understanding of regulatory, contractual, and operational responsibilities of Medicare Advantage plans and Health Maintenance Organizations. Medicare Compliance, medical claims processing/auditing experience, PBM, and/or pharmacy audit experience preferred. Project management experience and handling multiple high priority projects with competing deadlines. Working knowledge of laws and/or regulations in area of compliance; specifically, CMS MA/PD Program, HIPAA, FWA, and state department of insurance laws, regulations and administrative rules. Strong auditing background preferred. Bachelor’s degree required, preferably in business, finance, accounting, legal, or healthcare. Certification in Healthcare Compliance (CHC) or other relevant certification(s), or must obtain within the first 2 years of employment . Microsoft Outlook, Excel and Word required. Ability to learn HRIS and/or scheduling systems required.

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