Compliance Analyst II PACE/Medicare

Job Summary:

The Compliance Analyst II (PACE/Medicare) position is a professional compliance role responsible for supporting the Compliance Program by collaborating and overseeing high risk areas to ensure that the compliance program is effective and efficient in identifying, preventing, detecting, and correcting noncompliance.

Essential Functions:

Compliance Prevention:

• Provide analysis, interpretation, training, and education related to requirements as needed to ensure understanding and effective implementation of compliance requirements
• Support departments with requirement implementation, reporting development, policy and procedure development/review, and readiness testing
• Collaborate with internal business owners to ensure implementation of the health plan's business and contractual requirements
• Work with Compliance leadership to interpret regulations and provide related guidance
• Assists in review and dissemination to team of Regulatory Distribution Management items (new and changing regulations); works to understand and provide expertise to team on these items and the impact to our work with high-risk business areas

• Provide Compliance Program support with audit and monitoring, corrective action plan management, data analytics and other projects to ensure proper execution of the Compliance Program workplan and priorities
• Analyze relevant business and/or delegate/FDR performance data to ensure compliance with requirements and prepare reports for leadership and business owners
• Proactively use analytic and research skills to identify potential areas of risk to CareSource and make recommendations or escalate to Compliance Management for issue management, external audit enforcement trending, and related industry corrective actions
• Support and/or coordinate audit activities with impacted business owners to ensure adequate representation from subject matter experts (SME) for external reviews and audits
• Proactively maintain documentation, data universes, responses and other written or electronic materials using the proper compliance tools and in accordance with Corporate Compliance protocols

• Investigate risks and issues with effective research, root cause analysis, and gap analysis for effective remediation and corrective action management

• Ensure timely, complete, accurate, and concise documentation of corrective action plans, case summaries and executive summaries for all compliance matters. Documentation must include problem, history, mitigation or corrective actions, and recommendations for ongoing monitoring or process improvement.

• Build and maintain positive and strategic relationships with internal and external stakeholders
• Attend all required state regulator meetings and communicate outcomes, manage deliverables, and provide guidance to business areas
• Perform any other job duties as requested

• Bachelor's degree in business or related field, or equivalent years of relevant work experience is required
• Minimum of three (3) years of compliance and/or regulatory experience including one (1) year in Government Program products is required

• Strong familiarity with government-funded healthcare programs, including PACE, Medicaid, Marketplace, and Medicare, and the compliance standards imposed upon First Tier, Downstream and Related (FDR) entities
• Familiarity with Healthcare operations and/or clinical concepts, practices and procedures is preferred
• Data analysis ability to produce meaningful insight and drive appropriate action
• Demonstrated understanding of Compliance and Regulatory fundamentals specifically related to managed care and government programs (CMS/HHS/DOI/Medicaid)
• Proven knowledge of internal and external audit functions and procedures
• Ability to conduct research and analysis of Federal, State, and relevant industry regulatory and enforcement
• Proven ability to effectively manage work through prioritization, preparing, effective scheduling, leveraging resources and maintaining focus
• Demonstrated professional communication skills, to include proper grammar usage, document structure, and business writing to audiences including but not limited to internal Leadership at all levels, internal and external Legal Counsel, Corporate Compliance, State and Federal Regulators
• Advanced organizational, project management and scheduling skills
• Strong decision making and problem-solving skills
• Ability to work independently and within a team environment
• Demonstrated success in working in a matrixed environment
• Detail orientated with focus on maintaining accurate information in tools as required
• Demonstrated critical thinking skills
• Negotiation skills/experience
• Time management skills including creation and maintenance of project timelines
• Advanced level experience in Microsoft Word, Excel and PowerPoint

• Certified in Healthcare Compliance (CHC) or Certified Compliance and Ethics Professional (CCEP) preferred
• Current, unrestricted clinical licensure to include: LPN in state of service, Registered Nurse (RN) in the state of service, or other clinical licensure may be desired for positions with a clinical focus
• Functional business licensure/ certification may be desired as they apply to organizational operations (e.g. Claims coding certification, analytics certification, etc.)

• General office environment; may be required to sit or stand for extended periods of time

• Create an Inclusive Environment
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business