Compliance Analyst

Imperial Health Plan of California, Inc.; Pasadena (CA); On-site; USD 85,000 - 110,000; Full time

Job summary

Imperial Health Plan of California, Inc. is seeking a Compliance Analyst in Pasadena, CA, to coordinate oversight activities with Imperial and related entities per CMS requirements for FWA prevention and Medicare program compliance.

The role reports to the Compliance Officer and requires collaboration with the Compliance Department on seven elements of a compliance program, CMS data submissions, and internal audits. A strong background in healthcare regulations and audit practice is expected.

Qualifications

• High school graduate or equivalent.
• Bachelor's degree preferred; 3–5 years in health plan/healthcare setting.
• 2 years healthcare compliance experience or CMS/state regulatory agency experience.
• 2 years of experience with regulatory requirements.
• Audit experience preferred.

Responsibilities

• Support accurate and complete reporting of compliance activities to the compliance committees and external oversight entities.
• Review regulatory communications applicable to the organization and FDRs and ensure appropriate action is taken.
• Perform and assess effectiveness of regulatory compliance training and education activities.
• Coordinate and perform ongoing internal monitoring of activities, including tracking compliance and implementing action as required.
• Perform audits of operational areas and FDRs to determine CMS compliance and internal controls.
• Review and submit comments for internal marketing reviews prior to CMS approval.
• Participate in CMS webinars, seminars, and conference calls relevant to responsibilities.
• Coordinate timely completion of CMS and state reporting requirements and other submissions.
• CMS data submission quality checks and update tools as necessary.
• Monitor and communicate CMS analyses and other compliance reports.
• Investigate and respond to potential non-compliant or FWA activity.

Skills

CMS regulations

Healthcare compliance

Regulatory requirements

Auditing

Communication skills

Data privacy

Education

Bachelor's degree preferred

High school graduate or equivalent

Job description

Job Summary

Will coordinate the compliance oversight activities for Imperial and with first-tier, downstream, and related entities (FDRs), as necessary, to meet the contractual oversight regulatory requirements for the prevention, detection, and correction of Fraud, Waste and Abuse (FWA) and Medicare program non-compliance as established by the Centers for Medicare and Medicaid Services (CMS).

Job Description

JOB TITLE: Compliance Analyst

FLSA STATUS: Exempt

DEPARTMENT: Compliance

REPORTS TO: Compliance Officer

Will coordinate the compliance oversight activities for Imperial and with first-tier, downstream, and related entities (FDRs), as necessary, to meet the contractual oversight regulatory requirements for the prevention, detection, and correction of Fraud, Waste and Abuse (FWA) and Medicare program non-compliance as established by the Centers for Medicare and Medicaid Services (CMS).

Essential Job Functions

• Support the accurate and complete reporting of compliance activities to the compliance committees and external oversight entities.
• Review and interpret all regulatory communications applicable to the organization and FDRs and ensure that appropriate action is taken, including dissemination to applicable areas and implementation of changes as needed.
• Perform and assess the effectiveness of regulatory compliance training and education activities applicable to the Exchange line of business and other regulatory requirements.
• Coordinate and perform ongoing internal monitoring of activities, including tracking compliance and implementing appropriate action as required.
• Perform audits of operational areas and FDRs, whether desk or off-site, in accordance with the annual workplan or through ad hoc audits to determine compliance with CMS operational and Compliance Program requirements, including validation of data and internal controls.
• Review and submit comments, when necessary, for all assigned internal marketing reviews prior to their submission to CMS for approval.
• Participate in CMS webinars, seminars, and conference calls applicable to assigned responsibilities.
• Be responsible for the issuance and management of compliance actions due to non-compliance resulting from reported issues, monitoring, and auditing activities.
• Coordinate the timely and accurate completion of CMS and state reporting requirements and other required submissions.
• Perform appropriate CMS data submission quality checks and update developed tools as necessary.
• Monitor, analyze, and communicate CMS analyses and other reports related to compliance.
• Investigate and respond to reported issues and incidents of potential non-compliant or FWA activities.
• Coordinate with internal departments and FDRs on issues related to compliance and FWA.
• Coordinate and assist the Compliance Department in preparation activities for regulatory site visits and reviews.
• Coordinate with other members of the Compliance Department or throughout the organization when assigned activities overlap or as directed by Management.
• For FDRs, perform pre-contract reviews, designation of prospective FDR contracts, and pre-assessments to ensure prospective entities have policies, operations, and staff to fulfill the proposed contracted activities of the plan.
• For FDRs, communicate information regarding Imperial Health Plan's Compliance Program and monitor their adherence to requirements.
• Be responsible for supporting the implementation of the seven elements of a compliance program and FDR oversight.
• Maintain regular and consistent attendance.
• Adhere to the Compliance Plan and HIPAA regulations.

Marginal Job Functions

• Take on special projects as needed.
• Perform other duties as assigned.

BEHAVIORAL EXPECTATIONS

Continuous Learning

• Attend staff meetings as required.
• Attend appropriate training, seminars, and workshops as required.

Customer Focus

• Maintain client/customer confidentiality and privacy in accordance with HIPAA regulations and Imperial's Standards of Conduct.
• Foster appropriate communication and relations with supervisors, co-workers, and other staff.

Quality/Process Improvement/Safety

• Report issues of security, health, and/or safety to the appropriate supervisor as soon as practicable.
• Support and demonstrate safety throughout all duties performed.
• Follow established policies and procedures and understand and comply with all regulatory standards set forth by governing entities.

Education/Experience

POSITION REQUIREMENTS

• High school graduate or equivalent.
• Bachelor's degree preferred and/or 3 to 5 years of related work experience in a health plan and/or healthcare setting.
• Required: 2 years of healthcare compliance experience or, in lieu thereof, two years working with a CMS government program or state regulatory agency.
• Required: 2 years of experience with regulatory requirements.
• Audit experience preferred.

Skills/Knowledge/Ability

• Strong computer skills, including proficiency in word processing, spreadsheets, and databases.
• Knowledge of CMS and state regulatory guidelines related to job functionality.
• Ability to work independently.
• Strong communication and interpersonal skills.
• Ability to meet deadlines.
• Ability to maintain an appropriate level of confidentiality and privacy.
• Willingness and ability to read, write, speak, and understand English and have the communication skills necessary to provide accurate information to members and staff.
• Willingness and ability to follow written and verbal direction in English.
• Willingness and ability to maintain an appropriate level of confidentiality and privacy.
• Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.
• Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.
• Willingness and ability to make appropriate judgments, decisions, and problem-solving in a timely manner and within the context of the situation at hand.
• Ability to effectively prioritize items/tasks as required.
• Willingness and ability to take initiative and be a self-starter.
• Willingness and ability to understand and comply with federal, state, and local regulations.

LICENSURE/CERTIFICATE/TRAINING

• Certified in Healthcare Compliance (CHC) preferred.