Senior Embedded Compliance Analyst - (Remote)

CareFirst, Inc.; Baltimore (MD); A distancia; USD 70.000 - 139.000; Jornada completa

Descripción de la vacante

CareFirst BlueCross BlueShield seeks a Senior Embedded Compliance Analyst to support Medicare Advantage regulatory activities, monitor KPIs/KRIs, and oversee CAP remediation. The role involves investigations, post-implementation checks, and collaboration with Ethics & Compliance to mature the program.

The ideal candidate has 5 years in health insurance compliance, preferred CHC/CRCMP/CCEP certifications, and strong analytical and communication skills. Travel up to 5% may be required.

Formación

• Bachelor's degree required; 4 additional years of relevant work experience may substitute.
• 5 years of experience in health insurance industry, managed care, or related compliance programs.
• Preferred certifications: CHC, CRCMP, CCEP, Lean Six Sigma; others welcome.
• Knowledge of CMS programs (Medicare/Medicaid) and regulatory frameworks.
• Strong analytical and reporting abilities; effective communication with stakeholders.

Responsabilidades

• Monitor compliance performance for Medicare Advantage using KPIs/KRIs.
• Collaborate with business owners to address remediation and ensure CAP implementation.
• Support post-implementation procedures validating compliance requirements.
• Investigate and address compliance incidents with timely, professional responses.
• Coordinate with Corporate Ethics & Compliance on Code of Conduct and third-party conduct.

Conocimientos

Regulatory compliance

Stakeholder management

Analytical thinking

Regulatory reporting

Communication skills

Educación

Bachelor's Degree in Business Administration, Healthcare Compliance or related field

4+ years relevant work experience in lieu of degree

Herramientas

Word

Excel

Database management

Descripción del empleo

Resp & Qualifications

PURPOSE:

The Senior Embedded Compliance Analyst will support Corporate Compliance and its defined Compliance Program by performing compliance activities for Medicare Advantage while providing review and analysis of regulatory rules / guidelines, monitoring the organization's compliance performance, tracking Key Performance Indicators (KPIs)/Key Risk Indicators (KRIs), and supporting Program Integrity and Fraud, Waste, and Abuse (FWA) efforts. The Analyst will also help to monitor corrective action plans, established to address identified compliance issues, and perform post-evaluation procedures for compliance implementation and remediation activities.

ESSENTIAL FUNCTIONS:

• Monitors compliance performance based on a Compliance Risk Assessment to provide compliance oversight for MEDICARE ADVANTAGE. Review, analyze, and distribute regulatory rules / guidelines / contractual requirements to educate impacted CareFirst business areas and delegated entities. Identify and track required actions as the result of regulatory rules / guidelines / contractual requirements. Track and assess Key Performance and Key Risk Indicators (KPI / KRIs). Identify compliance risks by gathering, reviewing, and analyzing organizational data for downward trends or instances of non-compliance or potential non-compliance.
• Collaborate with business owners within MEDICARE ADVANTAGE to establish and monitor action plans to address remediation of compliance risks. Help ensure that a root cause analysis is performed to address underlying issues when an action plan is needed. Follow up with stakeholders to help ensure remediation efforts are on track, successful, and validate that action plans have been implemented correctly. Regularly monitor CAP implementation and communicate and report risks associated with identified control deficiencies to stakeholders. Provide reporting to the Compliance leadership, documenting CAP results and escalating risks and issues related to identification, implementation, and remediation.
• Assist with the performance of post implementation procedures to validate performance of compliance requirements resulting from mandates, regulatory and contractual changes, systems, or partner implementations for MEDICARE ADVANTAGE.
• Perform investigations, research, and due diligence to address compliance incidents, events, research, inquiries, and concerns from leadership forMEDICARE ADVANTAGE. Perform assessments to identify compliance risks preceding or in parallel to compliance incidents, events, company initiatives, Provide professionally written and audit-appropriate responses to the originating party, ensuring questions are answered and customer needs are effectively served within designated time frames while respecting the privacy needs of members.
• Collaborate with Corporate Ethics & Compliance on Code of Conduct and Third-Party Code of Conduct to ensure compliance.Support and drive the continued to maturity of CareFirst compliance through on-going education, development of compliance tools, compliance initiatives, and collaboration with other compliance risk functions (e.g., Internal Audit, Executive Inquiry, Privacy) to respond to compliance incidents, gaps, and identified risks. Supports the development, implementation, and maintenance of written policies and procedures. for MEDICARE ADVANTAGE. Collaborate and contribute to standards of conduct.

QUALIFICATIONS:

Education Level: Bachelor's Degree in Business Administration, Healthcare Compliance or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications Preferred:

• CHC - Certified Healthcare Compliance or
• CRCMP- Certified Risk And Compliance Professionalor
• Lean Six Sigma Certification-IASSCor
• Certified Regulation Analystor
• Certified Compliance & Ethics Professional (CCEP)

Experience: 5 years experience in health insurance industry, managed care and government programs, health insurance compliance programs, or related fields.

Preferred Qualifications:

• Healthcare Compliance certification(s).
• Experience in CMS programs (Medicare or Medicaid, project management, business process analysis, workflow, and task analysis.
• Process Improvement Systems training in Six Sigma, Lean, or other Business Process Improvement tools.

Knowledge, Skills and Abilities (KSAs)

• Excellent interpersonal skills with ability to build consensus and agreement and bring resolution to contentious issues and 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/guidance, and exhibit sound judgment in determining a recommendation or solution to a problem.
• Word, Advanced Excel and database management and related software applications.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Travel Requirements

Estimate Amount: 5% Travel to CareFirst locations or training may be necessary.

Salary Range: $70,200 - $139,425

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Medicare Compliance Office

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of theCompany to provide equal employment opportunities to allqualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship