Senior Compliance & Ethics Analyst (Remote)

CareFirst•Baltimore, MD

2d•Remote

About The Position

The Senior Ethics & Compliance Analyst supports the organization’s ethics and compliance function and defined Ethics & Compliance Program. The role helps implement and maintain the annual Compliance Workplan; reviews and analyzes regulatory rules, guidelines, and contractual requirements; monitors compliance performance; tracks KPIs and KRIs; and supports Program Integrity and Fraud, Waste, and Abuse (FWA) efforts. The analyst also monitors Corrective Action Plans (CAPs) addressing identified compliance issues and performs post-evaluation procedures for compliance implementation and remediation activities. The position collaborates with business owners and stakeholders on remediation plans, root cause analyses, and validation that corrective actions are implemented effectively. It identifies and reports compliance risks, analyzes organizational data for potential non-compliance, conducts investigations and risk assessments, and prepares timely, accurate, audit-ready responses while adhering to member privacy requirements. The analyst supports compliance education and tools, written policies and procedures, standards of conduct, compliance committees, training and attestation processes, and reviews member materials for applicable regulatory, contractual, company, and BCBSA requirements. The role may prepare and submit materials to regulators as applicable.

Requirements

Bachelor’s degree.
Five years of knowledge of ethical and corporate compliance, with demonstrated ability to apply elements of the Federal Sentencing Guidelines for organizations and experience with compliance and/or regulatory or legal programs.
Knowledge of compliance program development and maintenance.
Strong research and analytical skills.
Ability to work on multiple projects and shift priorities.
Proficiency in Microsoft Office applications.
Ability to meet established deadlines and handle multiple internal and external customer service demands within service expectations.
Ability to communicate effectively and provide positive customer service to internal and external customers, including demanding or challenging customers.
Must be eligible to work in the U.S. without sponsorship.

Nice To Haves

CHC (Certified Healthcare Compliance) or CCEP (Certified Compliance & Ethics Professional) certification within one year is preferred.
Operational experience in the health care or health care insurance industry, including a state Medicaid program or CMS Medicare Advantage program, is preferred.
Professional certification such as Certified in Healthcare Compliance (CHC), Certified Compliance Professional (CCP) by Health Ethics Trust, or Certified Compliance and Ethics Professional (CCEP).

Responsibilities

Collaborate with business owners to establish and monitor action plans for remediating compliance risks.
Ensure root cause analyses are performed when action plans are needed.
Follow up with stakeholders to monitor remediation progress and validate that action plans are implemented correctly.
Monitor CAP implementation and communicate and report risks associated with control deficiencies.
Report CAP results to Ethics & Compliance leadership and escalate risks and issues related to identification, implementation, and remediation.
Monitor compliance performance based on Compliance Risk Assessments.
Review, analyze, and distribute regulatory rules, guidelines, and contractual requirements to affected business areas and delegated entities.
Identify and track actions required by regulatory rules, guidelines, and contractual requirements.
Track and assess KPIs and KRIs.
Gather, review, and analyze organizational data to identify compliance risks, downward trends, and actual or potential non-compliance.
Establish, validate, and implement FWA safeguards concerning enrollee communications and excluded, sanctioned, or precluded providers, employees, enrollees, and entities.
Review required government exclusion lists consistently.
Conduct investigations, research, and due diligence concerning compliance incidents, events, inquiries, and leadership concerns.
Perform proactive and concurrent risk assessments for incidents, events, or company initiatives.
Prepare clear, professional, audit-ready responses to originating parties, ensuring timely resolution, complete and accurate answers, and adherence to member privacy requirements.
Support the ongoing development of the compliance program through education, compliance tools, initiatives, and collaboration with related risk functions.
Support the development, implementation, and maintenance of written policies and procedures.
Collaborate on and contribute to the Company’s standards of conduct.
Support maintenance of required Compliance committees.
Monitor required training and education for applicable parties and support third-party onboarding and annual attestations.
Perform post-implementation procedures to validate compliance requirements resulting from mandates, regulatory or contractual changes, systems, or partner implementations.
Review prospective and current member materials and other required materials for regulatory, contractual, Company, and BCBSA compliance.
Prepare and submit materials to regulators as applicable.