Compliance Analyst

Job Description

Job Description

JOB DESCRIPTION

JOB TITLE: Compliance Analyst
FLSA STATUS: Exempt
DEPARTMENT: Compliance
REPORTS TO: Compliance Officer

JOB SUMMARY

Will coordinate the compliance oversight activities for Imperial and with first-tier, downstream, and related entities (FDRs), as necessary, to meet the contractual oversight regulatory requirements for the prevention, detection, and correction of Fraud, Waste and Abuse (FWA) and Medicare program non-compliance as established by the Centers for Medicare and Medicaid Services (CMS).

ESSENTIAL JOB FUNCTIONS

• Support the accurate and complete reporting of compliance activities to the compliance committees and external oversight entities.

• Review and interpret all regulatory communications applicable to the organization and FDRs and ensure that appropriate action is taken, including dissemination to applicable areas and implementation of changes as needed.

• Perform and assess the effectiveness of regulatory compliance training and education activities applicable to the Exchange line of business and other regulatory requirements.

• Coordinate and perform ongoing internal monitoring of activities, including tracking compliance and implementing appropriate action as required.

• Perform audits of operational areas and FDRs, whether desk or off-site, in accordance with the annual workplan or through ad hoc audits to determine compliance with CMS operational and Compliance Program requirements, including validation of data and internal controls.

• Review and submit comments, when necessary, for all assigned internal marketing reviews prior to their submission to CMS for approval.

• Participate in CMS webinars, seminars, and conference calls applicable to assigned responsibilities.

• Be responsible for the issuance and management of compliance actions due to non-compliance resulting from reported issues, monitoring, and auditing activities.

• Coordinate the timely and accurate completion of CMS and state reporting requirements and other required submissions.

• Perform appropriate CMS data submission quality checks and update developed tools as necessary.

• Monitor, analyze, and communicate CMS analyses and other reports related to compliance.

• Investigate and respond to reported issues and incidents of potential non-compliant or FWA activities.

• Coordinate with internal departments and FDRs on issues related to compliance and FWA.

• Coordinate and assist the Compliance Department in preparation activities for regulatory site visits and reviews.

• Coordinate with other members of the Compliance Department or throughout the organization when assigned activities overlap or as directed by Management.

• For FDRs, perform pre-contract reviews, designation of prospective FDR contracts, and pre-assessments to ensure prospective entities have policies, operations, and staff to fulfill the proposed contracted activities of the plan.

• For FDRs, communicate information regarding Imperial Health Plan's Compliance Program and monitor their adherence to requirements.

• Be responsible for supporting the implementation of the seven elements of a compliance program and FDR oversight.

• Maintain regular and consistent attendance.

• Adhere to the Compliance Plan and HIPAA regulations.

MARGINAL JOB FUNCTIONS

• Take on special projects as needed.

• Perform other duties as assigned.

BEHAVIORAL EXPECTATIONS

Continuous Learning

• Attend staff meetings as required.

• Attend appropriate training, seminars, and workshops as required.

Customer Focus

• Maintain client/customer confidentiality and privacy in accordance with HIPAA regulations and Imperial's Standards of Conduct.

• Foster appropriate communication and relations with supervisors, co-workers, and other staff.

Quality/Process Improvement/Safety

• Report issues of security, health, and/or safety to the appropriate supervisor as soon as practicable.

• Support and demonstrate safety throughout all duties performed.

• Follow established policies and procedures and understand and comply with all regulatory standards set forth by governing entities.

POSITION REQUIREMENTS

EDUCATION/EXPERIENCE

• High school graduate or equivalent.

• Bachelor's degree preferred and/or 3 to 5 years of related work experience in a health plan and/or healthcare setting.

• Required: 2 years of healthcare compliance experience or, in lieu thereof, two years working with a CMS government program or state regulatory agency.

• Required: 2 years of experience with regulatory requirements.

• Audit experience preferred.

SKILLS/KNOWLEDGE/ABILITY

• Strong computer skills, including proficiency in word processing, spreadsheets, and databases.

• Knowledge of CMS and state regulatory guidelines related to job functionality.

• Ability to work independently.

• Strong communication and interpersonal skills.

• Ability to meet deadlines.

• Ability to maintain an ap