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We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.
We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
Preferred locations - TX, MN, FL
The Senior Compliance Analyst will be responsible for supporting the Compliance Officer in managing corporate compliance functions such as policy/procedure management, compliance hotline, conflict of interest, compliance training and regulatory change management. In addition, they will support responding to external Health Plan audits of utilization management, claims, and credentialing operations.
Duties and Responsibilities:
- Chair the Policy Review Committee and lead efforts to approve, review, and publish new and updated policies and procedures.
- Monitor the compliance hotline and compliance email address and work with the Compliance Officer to coordinate appropriate investigation and response to incoming reports.
- Review conflict-of -interest disclosures and work with the Compliance Officer to investigate and manage reported conflicts.
- Partner with human resources to ensure all annual and new hire compliance training is complete, and background/exclusions check are done for all employees.
- Assist Compliance Officer in investigating privacy incidents.
- Help coordinate compliance committee and board reports to include taking compliance committee minutes.
- Manage the intake and distribution of new regulations and guidance to applicable operational areas.
- Support responding to external Health Plan audits of utilization management, claims, and credentialing operations, by completing audit questionnaires, submitting polices, and preparing operational records requested.
Education and Experience:
- Bachelor's degree in a related field or equivalent experience.
- Minimum three (3) years experience in Health Plan/managed care compliance or operations experience required, UM and provider claims compliance highly preferred.
- Minimum three (3) years of experience performing compliance audits highly preferred.
- Experience in an MSO or ACO is preferred.
- Experience with accreditation or regulatory audits, including NCQA, CMS audits.
Professional Competencies:
- Ability to gather and analyze data sets
- Ability to work collaboratively with both internal and external stakeholders
- Knowledge of Health Plan operations
- Knowledge of Health Plan regulatory requirements
