JOB TITLE: Compliance Analyst

DEPARTMENT: Compliance

REPORTS TO: Compliance Officer

JOB SUMMARY: To 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

Research and provide regulatory guidance and interpretation to inquiries through the use of applicable regulatory guidance including the Medicare Managed Care Manual, Medicare Prescription Drug Benefit Manual, and other regulatory guidance

Perform and assess the effectiveness of regulatory compliance training and education activities applicable to Medicare Advantage 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 (desk or off-site) in accordance with annual workplan or 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

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 Part C and D Reporting Requirements and other required CMS 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

Responsible for supporting the implementation of the seven elements of a compliance program and FDR oversight.

MARGINAL JOB FUNCTIONS:

Takes on special projects as needed.

Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS:

Continuous Learning:

Attends staff meetings as required.

Attends appropriate training, seminars and workshops as required

Customer Focus:

Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations

and Compliance Standards of Conduct.

Fosters appropriate communication and relations with Supervisor, co-workers and other staff.

Quality/Process Improvement/Safety

Reports issues of privacy, security, health and/or safety to appropriate supervisor and or Compliance as soon as practicable.

Supports and demonstrates safety throughout all duties performed.

Follows established policies and procedures and understands and complies with all regulators

standards set forth by governing entities.

POSITION REQUIREMENTS:

EDUCATION/EXPERIENCE:

Required 2 years Medicare compliance experience or in lieu, two years working with CMS government program, including working knowledge of Medicare Advantage Prescription Drug plan organization and structure.

Medicare Audit experience preferred.

Certified in Healthcare Compliance (CHC) preferred.

Bachelor’s degree preferred and/or 3 to 5 years related work experience in a Medicare Advantage Plan.

SKILLS/KNOWLEDGE/ABILITY:

Professionalism required

Strong computer skills including proficiency in word processing, spreadsheet, and database management skills required

Ability to manage multiple tasks simultaneously

Ability to work independently

Excellent oral and written communication skills

Strong communications and interpersonal skills

Detail oriented

Excellent organizational skills

Ability to meet deadlines

Knowledge of CMS and State regulatory guidelines related to job functionality.

Ability to maintain an appropriate level of confidentiality and privacy.

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.

Ability to take initiative and be a self-starter.

Ability to understand and comply with Federal, State, and local regulations.

LICENSURE/CERTIFICATE/TRAINING:

• Certified in Healthcare Compliance (CHC) preferred