Senior Embedded Compliance Analyst - (Remote)
About The Position
The Senior Embedded Compliance Analyst supports Corporate Compliance and its Compliance Program by performing compliance activities for Medicare Advantage. The role helps implement and maintain the annual Compliance Workplan, reviews and analyzes regulatory rules and guidelines, monitors organizational compliance performance, tracks Key Performance Indicators (KPIs) and Key Risk Indicators (KRIs), and supports Program Integrity and Fraud, Waste, and Abuse 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 works with CareFirst business areas, delegated entities, Medicare Advantage business owners, and compliance partners to identify risks, coordinate remediation, validate corrective actions, respond to compliance matters, and support policies, procedures, education, and compliance tools. Travel to CareFirst locations or training may be necessary, estimated at 5%.
Requirements
- Bachelor's degree in Business Administration, Healthcare Compliance, or a related field; alternatively, an additional four years of relevant work experience may substitute for the degree, in addition to the required work experience.
- Five years of experience in the health insurance industry, managed care and government programs, health insurance compliance programs, or related fields.
- Excellent interpersonal skills and ability to build consensus, resolve contentious issues, and work through entrenched interests.
- Ability to present and discuss regulatory compliance goals in a way that establishes rapport, persuades others, and gains commitment.
- Ability to research complex issues, interpret regulations and regulatory rules or guidance, and use sound judgment to recommend solutions.
- Proficiency with Word, advanced Excel, database management, and related software applications.
- Ability to meet established deadlines and manage 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.
- Must immediately disclose any debarment, exclusion, or other event that makes the incumbent ineligible to perform work directly or indirectly on Federal health care programs.
Nice To Haves
- Healthcare compliance certification(s), such as CHC, CRCMP, Certified Regulation Analyst, or CCEP.
- Lean Six Sigma Certification (IASSC).
- Experience with CMS programs, including Medicare or Medicaid.
- Project management experience.
- Business process analysis, workflow, and task analysis experience.
- Training in Six Sigma, Lean, or other business process improvement tools.
Responsibilities
- Monitor Medicare Advantage compliance performance based on a Compliance Risk Assessment.
- Review, analyze, and distribute regulatory rules, guidelines, and contractual requirements to educate impacted business areas and delegated entities.
- Identify and track actions required by regulatory rules, guidelines, and contractual requirements.
- Track and assess Key Performance Indicators and Key Risk Indicators.
- Gather, review, and analyze organizational data to identify compliance risks, downward trends, and actual or potential non-compliance.
- Collaborate with Medicare Advantage business owners to establish and monitor remediation action plans.
- Help ensure root cause analyses are performed when action plans are needed.
- Follow up with stakeholders to ensure remediation is on track and validate that action plans are implemented correctly.
- Monitor corrective action plan implementation and communicate risks associated with control deficiencies.
- Report corrective action plan results to Compliance leadership and escalate related risks and issues.
- Perform post-implementation procedures to validate compliance with requirements resulting from mandates, regulatory or contractual changes, systems, or partner implementations.
- Conduct investigations, research, and due diligence concerning Medicare Advantage compliance incidents, events, inquiries, and leadership concerns.
- Perform assessments to identify compliance risks preceding or occurring alongside incidents, events, and company initiatives.
- Prepare professionally written, audit-appropriate responses to originating parties, answering questions and serving customer needs within designated time frames while respecting member privacy.
- Collaborate with Corporate Ethics & Compliance on the Code of Conduct and Third-Party Code of Conduct.
- Support continued maturity of CareFirst compliance through ongoing education, compliance tools and initiatives, and collaboration with functions such as Internal Audit, Executive Inquiry, and Privacy.
- Support the development, implementation, and maintenance of written policies and procedures for Medicare Advantage.
- Collaborate and contribute to standards of conduct.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Various incentive programs and plans, subject to eligibility requirements.
- 401(k) contribution programs and plans, subject to eligibility requirements.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
