Clinical Regulatory Oversight, Business Analyst III
About The Position
The Clinical Regulatory Oversight Business Analysts provides analytical documentation, and reporting support from prior authorization submission through claims payment to the Clinical Regulatory Oversight team. This role supports regulatory compliance activities impacting Clinical Services including Utilization Management (UM), Appeals, and Grievances (AG) and Care Management (CM) by assisting with audit readiness, NCQA deliverables, reporting requirements, and maintenance of regulatory documentation. The Business Analyst partners closely with Program Managers and cross-functional stakeholders to ensure regulatory requirements are accurately implemented, monitored, and supported by defensible data and documentation. Performs other duties as assigned.
Requirements
- Bachelor's degree or equivalent experience in related field.
- 5+ years of business analysis, regulatory support, compliance, quality, or healthcare operations experience beyond degree.
Nice To Haves
- Strong analytical, documentation, and organizational skills.
- Advanced proficiency in Microsoft Excel and Microsoft Office.
- Excellent written and verbal communication skills.
- Project Management skills.
Responsibilities
- Support internal, state, federal, and accreditation audits by gathering, organizing, and validating regulatory documentation and data.
- Maintain audit trackers, issue logs, evidence inventories, and corrective action tracking tools.
- Assist Program Managers with preparation of audit responses and follow-up materials.
- Assist with gathering State and Federal regulatory, NCQA, and internal reporting requirements that impact UM, AG and CM or operating models.
- Validate accuracy, completeness, and consistency of data across reports and source systems.
- Partner with analytics, operations, and vendors to resolve data discrepancies.
- Support implementation of new or updated State and Federal regulatory requirements by documenting workflows, requirements, and controls.
- Track implementation milestones and deliverables.
- Identify opportunities to improve regulatory tracking, reporting, and documentation processes.
- Maintain regulatory documentation inventories, crosswalks, and version control logs.
- Support updates to policies, procedures, job aids, and letter templates under direction of Program Managers.
- Ensure documents align with regulatory, accreditation, and internal standards.
- Collaborate with Program Managers, compliance, operations, quality, and analytics teams.
- Prepare summaries, trackers, and presentation materials for leadership and governance forums.
Benefits
- competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
