Compliance Analyst III – Delegation Oversight

Sutter Health•Sacramento, CA

5d•Hybrid

About The Position

The Delegation Oversight Compliance Analyst supports the implementation and ongoing execution of the health plan’s delegation oversight program, helping ensure compliance with DMHC, Knox Keene, CMS, and NCQA requirements. This role contributes to the oversight of delegated entities (e.g., medical groups, subcontracted plans, vendors) across key functions such as utilization management, claims processing, grievances and appeals, credentialing, and care management. The analyst is responsible for supporting the full delegation oversight lifecycle, including coordination of pre-delegation assessments, facilitation of audits, monitoring of delegated entity performance, and tracking of corrective action plans (CAPs). The role assists in ensuring that delegated entities meet regulatory, contractual, and operational requirements, and that the health plan maintains appropriate oversight and accountability in accordance with California regulatory expectations. Key responsibilities include preparing and organizing audit documentation, supporting audit execution and follow-up activities, maintaining oversight trackers and dashboards, analyzing performance and compliance data, and identifying potential risks or gaps. The analyst partners with internal stakeholders to support timely issue resolution and continuous quality improvement. This role also supports governance and reporting processes, including preparation of materials for committee meetings, tracking regulatory reporting requirements, and maintaining documentation to demonstrate audit readiness. The analyst serves as a point of coordination with delegated entities to collect required information, support oversight activities, and ensure timely submission of required deliverables.

Requirements

Bachelor's in Business Administration or related field
5 years recent relevant experience.
In-depth knowledge of effective healthcare ethics and compliance program, including requirements, management, monitoring, conducting and documenting investigations, addressing violations, tracking corrective actions, and training.
Knowledge of healthcare clinical operations, hospital revenue cycle systems, healthcare billing and coding requirements, or other healthcare compliance requirements/issues.
Knowledge of medical terminology, standard medical abbreviations, and the disease process as well as general legal terminology, principles, procedures, and available legal resources.
Familiar with healthcare industry, including current trends, cultural concerns, and local/state/federal regulations, such as the CA Knox-Keene Act, California Insurance Code, Office of Inspector General (OIG) Work Plan, Affordable Care Act (ACA), and HIPAA regulations, in addition to federal and state reimbursement program requirements (e.g., Medicare and Medi-Cal).
Attention to detail with time management and organization skills, including the demonstrated ability to strictly adhere to multiple timelines.
Understanding of business acumen and analytic skills with the proven ability to analyze data and information, reach practical conclusions, recommend corrective actions, resolve conflicts, and institute effective changes.
Excellent written/verbal communication, interpersonal, and presentation skills with the ability to understand legal and regulatory requirements, healthcare laws, or sensitive information clearly and diplomatically to diverse audiences.
Proficient computer skills, including competency in Microsoft Office Suite (Word, Excel, and PowerPoint), Visio, Project, Crystal Reporting, and other software.
Ability to manage and organize large amounts of data in an efficient and clear manner, specifically in a regulatory and compliance-filing function.
Ability to identify potential concerns and compliance issues, and then assist in the development and implementation of actionable recommendations or process improvements to resolve the problem.
Ability to advise management and other stakeholders regarding the impact of emerging industry trends in compliance enforcement, legislation and regulations.
Ability to abstract information from medical records, reports, chart entries, related patient documentation, and interviews while conducting audits and investigations.
Ability to work independently, as well as part of a multidisciplinary team, while efficiently and effectively conducting audits and investigations within established timeframes and government regulations.
Ability to manage, prioritize, and drive multiple projects while navigating competing priorities to deliver quality products and services on-time and on-budget.
Ability to make informed decisions based on the analysis of multiple sources of information while providing new perspectives on existing solutions.
Ability to foster an open and collaborative environment that invites discussion about the compliance process and its value, influences individuals or groups with diverse opinions, builds consensus, and enlists cooperation without direct control/authority.
Ability to maintain strict confidentiality of sensitive material (compliance and risk management data) and ensure the privacy of each patient’s protected health information (PHI).
Ability to work effectively with staff, peers, senior management, physicians, state/federal agencies, and external organizations.
Ability to build collaborative working relationships with peers, other departments, stakeholders, management, vendors, and government agencies to achieve compliancy.

Nice To Haves

Equivalent experience will be accepted in lieu of the required degree or diploma.

Responsibilities

Supports the implementation and ongoing execution of the health plan’s delegation oversight program.
Contributes to the oversight of delegated entities across key functions such as utilization management, claims processing, grievances and appeals, credentialing, and care management.
Supports the full delegation oversight lifecycle, including coordination of pre-delegation assessments, facilitation of audits, monitoring of delegated entity performance, and tracking of corrective action plans (CAPs).
Assists in ensuring that delegated entities meet regulatory, contractual, and operational requirements.
Prepares and organizes audit documentation.
Supports audit execution and follow-up activities.
Maintains oversight trackers and dashboards.
Analyzes performance and compliance data, and identifies potential risks or gaps.
Partners with internal stakeholders to support timely issue resolution and continuous quality improvement.
Supports governance and reporting processes, including preparation of materials for committee meetings, tracking regulatory reporting requirements, and maintaining documentation to demonstrate audit readiness.
Serves as a point of coordination with delegated entities to collect required information, support oversight activities, and ensure timely submission of required deliverables.