Compliance Analyst III

Position Summary
The Compliance Analyst III for Medicare Appeals & Grievances is responsible for ensuring compliant, accurate, and timely handling of member appeals, grievances, in accordance with CMS regulations. This senior-level role provides advanced regulatory expertise, conducts targeted monitoring and auditing of A&G functions, develops corrective action plans, and supports operational teams in maintaining high-quality, member-focused outcomes. The analyst acts as a subject-matter expert for Parts C & D requirements, driving proactive compliance and operational excellence across the organization.

Key Responsibilities

Regulatory Expertise & Guidance

• Serve as the primary SME for CMS Part C & D requirements, including the Medicare Managed Care Manual - Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, Program Audit Protocols, and HPMS guidance.
• Monitor regulatory updates and identify impacts to A&G workflows, documentation, intake channels, notifications, and timeliness standards.
• Translate complex regulatory requirements into clear operational expectations for A&G leadership and frontline teams.

A&G Monitoring & Audit Activities

• Plan and perform routine and targeted A&G audits, including timeliness reviews, case accuracy assessments, proper classification, escalation handling, and decision rationale quality.
• Conduct root cause analysis on errors, operational breakdowns, or CMS notices of non-compliance related to A&G.
• Support internal mock audits and external CMS, state, or delegation oversight audits focused on A&G processes.
• Draft audit reports summarizing findings, risk levels, and recommended corrective actions.

Corrective Action & Quality Improvement

• Collaborate with A&G operations management to track and validate corrective action plans.
• Monitor CAP implementation for sustainability and assess ongoing risk exposure.
• Identify systemic trends and partner with cross-functional teams (UM, Claims, Provider Relations, Enrollment, Customer Service) to address upstream drivers of A&G issues.

Operational Support & Compliance Integration

• Provide compliance consultation during system changes, workflow redesigns, intake process changes, or vendor/delegate updates impacting A&G.
• Review member notices, templates, and scripts to ensure regulatory compliance, accuracy, and clarity.
• Support delegation oversight activities for vendors processing A&G cases, including monitoring, SLA reviews, and on-site or virtual audits.

Training & Communication

• Develop and deliver training for A&G staff on regulatory changes, audit findings, documentation expectations, and accuracy standards.
• Communicate trends, risks, and guidance through written summaries, dashboards, and presentations to leadership.

Reporting & Analysis

• Analyze A&G case performance data (e.g., timeliness, overturn rates, grievances by category, CTM trends).
• Prepare high-quality reports for the Compliance Committee, senior leadership, and quality forums.

Education & Experience

• Bachelor's degree in Healthcare Administration, Public Policy, Business, or related field (Master's preferred).
• 5-7+ years Medicare Advantage experience with at least 3-5 years directly in Appeals & Grievances, Quality, or Compliance.
• Strong knowledge of CMS Parts C & D A&G requirements, Program Audit Protocols, notices requirements, escalation processes (fast track, CDAG, ODAG), and timeliness rules.
• Experience interacting with CMS systems such as CTM, HPMS, and audit portals preferred.
• Prior experience conducting audits, root cause analysis, and compliance monitoring.

Skills & Competencies

• Exceptional analytical skills with high attention to detail and accuracy.
• Strong ability to interpret, apply, and communicate regulatory requirements.
• Excellent writing skills, especially for audit reports and regulatory summaries.
• Ability to influence without authority and collaborate effectively with operations.
• Strong time management and organizational skills in a fast-paced, highly regulated environment.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.