Senior SIU Compliance Analyst

Group Health Cooperative•Altoona, WI

About The Position

The Senior SIU Compliance Analyst supports the Special Investigations Unit’s compliance with federal and state fraud, waste, and abuse (FWA) program integrity requirements across multiple states. The role serves as a subject matter expert for SIU regulatory reporting, audit readiness, regulatory interpretation, and documentation standards. It partners with SIU leadership, Compliance, Legal, operational teams, external regulatory agencies, law enforcement, and contracted partners to support accurate reporting, effective oversight, timely issue resolution, and audit-defensible SIU processes. The analyst conducts quality reviews and audits of FWA files; collects, analyzes, monitors, and validates data and work activities; interprets regulatory guidance; and leads implementation of compliant SIU processes. The role develops and maintains policies, procedures, methodologies, and monitoring activities; prepares and coordinates required regulatory reports; supports internal and external audits; and provides guidance and training on SIU compliance expectations. It also leads improvements to SIU policies, tools, and workflows, supports corrective actions, and manages complex regulatory compliance projects across programs and states. This is a full-time position with an outstanding benefits package, including three weeks of vacation in the first year, a generous retirement plan, health and dental insurance, and a wellness program.

Requirements

Bachelor’s degree or equivalent in Business, health care operations, nursing, law, or another related area; or equivalent.
Seven years of relevant experience in health care compliance, SIU, audit, regulatory analysis, or regulatory reporting.
Advanced analytical, problem-solving, and documentation skills.
Experience in the legal or regulatory field; healthcare focus is desirable.
Project management, program development, and implementation experience.
Proven ability to produce audit-defensible work products and lead regulatory deliverables.
Experience with CMS or state program integrity audits or responses.

Nice To Haves

Master’s degree preferred.
Five years of demonstrated experience with FWA regulations and program integrity requirements, including CMS, OIG, Medicaid, MFCU, or related oversight programs, preferred.

Responsibilities

Conduct quality reviews and audits of FWA files for accuracy, completeness, timeliness, and adherence to departmental standards and regulatory requirements.
Collect, analyze, monitor, and validate data and work activities to identify gaps, support corrective action, and maintain audit-defensible documentation.
Coordinate with SIU leadership, internal stakeholders, external regulatory agencies, law enforcement, and contracted partners to support ongoing requirements and ad hoc requests.
Interpret regulatory guidance and lead implementation of compliant SIU processes.
Develop, implement, and maintain process improvements, departmental policies, procedures, methodologies, and monitoring activities.
Review and monitor adherence to documented plans and recommend corrective action when gaps are identified.
Prepare, validate, and coordinate timely submission of required SIU reports to federal and state regulatory agencies, including CMS, OIG, MFCU, Medicaid agencies, and other applicable oversight entities.
Ensure regulatory reporting is accurate, complete, timely, and supported by appropriate documentation.
Support internal and external audits, including CMS, Medicaid Program Integrity, HSAG, and related regulatory reviews.
Maintain current knowledge of laws, regulations, contractual requirements, and regulatory guidance affecting health plan SIU operations, FWA oversight, health insurance delivery, and reimbursement.
Apply regulatory requirements to daily work, provide guidance to internal partners, and support training or education related to SIU compliance expectations.
Lead development and refinement of SIU policies, procedures, job aids, tools, and workflows to improve consistency, efficiency, and regulatory compliance.
Identify process gaps, recommend solutions, and support implementation of corrective actions to mitigate compliance and audit risk.
Manage and support complex projects related to SIU regulatory compliance across multiple programs and states.
Identify best practices, evaluate their applicability to SIU operations, develop recommendations and action plans, and communicate findings, risks, and outcomes to SIU leadership and cross-functional stakeholders.