Compliance Analyst

Alivia Health• GUAYNABO, PR, US, PR

23d•Onsite

About The Position

The Compliance Analyst is responsible for supporting the organization’s compliance program through monitoring, analysis, investigations, and risk identification activities. This role focuses on ensuring adherence to applicable laws, regulations, internal policies, and contractual requirements, while promoting a culture of integrity, accountability, and continuous improvement. The Compliance Analyst works cross-functionally to identify compliance risks, support mitigation strategies, and enhance the effectiveness of the Quality & Compliance Program.

Requirements

A minimum of three (3) years’ of experience in pharmacy field and performing audits in billing and coding, pharmacy records review, clinical information extraction, medical terminology, and risk identification in operational areas.
Bachelor’s degree in business administration, Healthcare Administration, Health Sciences, or related field required.
Pharmacy Technician associate’s degree.
Ethical leadership skills and able to lead by the values of the organization.
Demonstrated emotional intelligence and diplomacy when engaging with others.
Demonstrated advanced verbal and written communication skills.
Ability to keep sensitive information confidential.
Possess a facilitating mindset to build strong customer connectivity.
Project management skills.
Demonstrated problem solving skills.
The ability to work independently and as part of a team.
Ability to maintain objectivity and lack bias in evaluations.
Critical thinking ability (analytical) with excellent organizational skills.
Detail oriented.
Knowledge of Microsoft Office programs (Word, Excel, Power Point) is required.
Basic knowledge in data analysis technique.
Fully bilingual in English and Spanish (Written and Verbal) REQUIRED EDUCATION, TRAINING & LICENSURE/CERTIFICATIONS.
For Pharmacy Technician it is required to have a license and registration.
For other related health Since related field will depend on the specialty and requirements by applicable health boards.

Nice To Haves

Certification in billing and coding, such as Certified Coding Associate (CCA), or Certified Coding Specialist (CCS), or Certified Risk Adjustment Coder (CRC), or Certification in Medical Billing, or ICD-10-CM are preferred.

Responsibilities

Review operational processes and related documentation and controls of pharmacy records and associated claims applying expertise in coding guidelines, medical policies, and payment procedures.
Conduct desktop reviews, on-site audits and monitoring activities of the pharmacy network and third-party vendors to ensure the appropriateness of billing practices and compliance with regulatory requirements.
Perform contract reviews to evaluate and ensure compliance with all applicable laws, regulations, and specific contractual obligations.
Collaborate in the administration of the exclusion list screening process (e.g., OIG, GSA, and other regulatory bodies).
Collect, analyze, and interpret data to identify trends, anomalies, and potential compliance risks.
Support the development of reports, dashboards, and metrics to monitor compliance performance.
Review pharmacy records, claims, prescriptions, employee documentation, contracts, licenses, and other relevant billing-related information to identify potential risks, compliance gaps, and operational improvement opportunities.
Conduct or support investigations related to compliance concerns, including Fraud, Waste, and Abuse (FWA), complaints, inquiries and Social Determinants of Health (SDOH) cases.
Triage and channel findings from investigations to the appropriate departments for resolution or intervention.
Document findings and provide recommendations for corrective actions.
Assist in the development and implementation of corrective action plans (CAPA).
Monitor effectiveness of corrective actions and identify opportunities for process improvement.
Identify and document the root cause that led to the identified error to design the corresponding action plan.
Support regulatory readiness and compliance with accreditation standards (e.g., URAC, ACHC, Joint Commission).
Assist with audits, surveys, complaints management and regulatory requests (e.g., RFIs).
Ensure adherence to state and federal laws and regulations, internal policies, and contract requirements.
Supports all functions related to Q&C Department internal/external reporting activities.
Collects, prepares, reviews, and submits requested information, data, and documents to Executive Management Staff.
Collaborate with the Q&C team, as needed to meet department goals, and perform other duties as assigned.
Supports the Quality and Compliance Leadership in the administration of the Quality & Compliance Program and objectives.
Actively supports Alivia Health Core Values and Mission through professional behavior and daily job performance.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
Support the development, review, and maintenance of compliance-related policies and procedures.
Ensure proper documentation and recordkeeping of compliance activities.
Collaborate with business units to address compliance risks and improve processes.
Provide guidance and support to operational teams on compliance-related matters.
Analyze and review confidential and highly sensitive investigative material/documents concerning insured, prescribers, or employees.
Detect and correct potential errors that may result in potential recovery to the company.
Give recommendations to the management team for possible solutions or improvement.
Support compliance training and education initiatives.
Promote awareness of compliance requirements and ethical standards.
Develop and deliver training programs and awareness material, serving as the primary resource for compliance education and ongoing staff development.
Prepare and present compliance reports, findings, and recommendations to leadership.
Escalate significant compliance risks or issues as appropriate.
Prepare and submit required fraud, waste, and abuse “FWA” reports to the management team, payors and/or regulatory agencies.
Support in the regulatory agencies' request for information “RFI” received.
Work with business units’ heads and staff to identify monitoring areas; collect, analyze, and interpret data and report results of monitoring initiatives.