Senior Analyst, Corp Compliance

CVS Health•Island, KY

2d•$46,988 - $112,200

About The Position

The Senior Analyst, Compliance COE will be a key member of the Compliance Monitoring team and execute assigned compliance monitoring activities. The role applies healthcare compliance, billing, coding, and risk adjustment knowledge to assigned activities, which may include complex or concurrent reviews across multiple business areas. It requires knowledge of Medicare Advantage, CMS risk adjustment programs, HCC coding, RAF methodologies, medical record validation, provider documentation standards, claims integrity, and coding compliance requirements. The role also coordinates assigned monitoring activities, including reporting results, following up on issues, and communicating compliance risks and business impacts.

Requirements

At least 2 years of experience in healthcare compliance, auditing, monitoring, billing, coding, claims review, medical record review, risk adjustment, investigations, or risk assessments within a healthcare organization, provider practice, health plan, or government healthcare program.
Strong knowledge of CMS Medicare Part B and Part C requirements, Medicare Advantage risk adjustment programs, HCC coding, RAF methodologies, provider documentation standards, medical record validation, coding compliance requirements, and documentation support standards for billed services and submitted diagnosis codes.
Experience reviewing medical records, claims data, diagnosis codes, modifiers, and supporting documentation to determine whether HCC submissions, RAF impact, billed services, and coding outcomes are accurate, complete, and supported.
Strong analytical, deductive, problem-solving, and critical-thinking skills.
Willingness to travel up to 5%, including by plane.
Bachelor's degree; equivalent work experience may substitute.
High school diploma or GED required.
Certified Professional Coder (CPC) required.

Nice To Haves

Ability to collaborate across Compliance, Legal, clinical operations, billing, coding, finance, and business teams to evaluate risk and support timely issue resolution.
Ability to facilitate meetings and communicate information clearly in written and verbal form.
Ability to evaluate information, identify compliance risks, solve complex problems, and recommend practical solutions using sound judgment.
Ability to identify opportunities to use automation and analytics to improve monitoring efficiency and provide actionable information to first-line business partners.
Strong cross-functional communication and relationship-building skills, including the ability to communicate results to management and other stakeholders in a matrixed organization.
Demonstrated ability to coordinate assigned activities, execute and document monitoring testing, and communicate results.
Experience analyzing claims, encounter, billing, coding, and documentation data to identify trends, outliers, control gaps, and compliance risk.
Strong business acumen, organizational and time-management skills, and attention to detail, with the ability to synthesize compliance results and findings clearly.

Responsibilities

Execute assigned compliance monitoring activities, including complex or concurrent reviews across multiple business areas.
Coordinate assigned monitoring activities, including results reporting, issue follow-up, and communication of compliance risks and business impacts.