Compliance Analyst III

Job Summary:

The Compliance Analyst III is a professional compliance role responsible for supporting the Compliance program by focusing on areas of risk assessment to effectively stratify compliance risk, detection of non-compliance through various compliance activities, and corrective action support for identified issues of non-compliance. This role is critical to assist the organization to determine adherence to internal standards and government/contractual requirements as they apply to the products, services, and/or operational areas assigned.

Essential Functions:

• Provide Compliance Program support with audit and monitoring, corrective action management, data analytics and other projects to ensure proper execution of the Compliance Program workplan and priorities

• Support the Compliance Program by collaborating and oversight of high risk areas to ensure that the compliance program is effective and efficient in identifying, preventing, detecting, and correcting non-compliance

• Assist in execution of risk assessment, work plan, and other compliance activities

• Support implementation, policy and procedure creations, training, education, and external reviews

• Provide expert analysis, interpretation, training and education related to regulatory requirements as needed to ensure understanding and effective implementation of compliance requirements and provide related guidance

• Provides Business Area support related to requirements as needed to ensure understanding and effective implementation of compliance requirements

• Support departments with requirement implementation, including implementation of the health plans’ business and contractual requirements, reporting development, policy & procedure development/review, and readiness testing

• Assist Compliance Management in development and performance of the annual compliance audit and monitoring workplans and activities using the proper Corporate Compliance tools in an effort to detect issues of non-compliance

• Plan and execute audit and monitoring activities

• Proactively use analytic and research skills to identify potential areas of risk to CareSource and timely make recommendations or escalate to Compliance Management for issue management, external audit enforcement trending, and related industry corrective actions

• Ensure timely, complete, accurate, and concise documentation of corrective action plans, case summaries and executive summaries for all compliance matters. Documentation must include problem, history, mitigation or corrective actions, and recommendations for ongoing monitoring or process improvement

• Develop and maintain corrective action plan information through conclusion

• Lead research, root cause and gap analysis

• Analyze deficiencies to determine root cause of non-compliance to effectively and thoroughly address the matter and fully develop appropriate corrective actions accordingly

• Lead quality orientation, follow procedures, ensure high-quality output, and take action to correct deficiencies

• Maintain information in compliance tools as required

• Develop and maintain positive and strategic relationships with internal and external stakeholders

• Support management onboarding of new team members through mentorship, shadowing, and training of all required functions and processes

• Assists in review and dissemination to team of Regulatory Distribution Management items (new and changing regulations); works to understand and provide SME to team on these items and the impact to our work with high-risk business areas

• Manage State/Federal Regulator inquiries

• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree in business or related field, or equivalent years of relevant work experience is required

• Minimum of five (5) years of compliance and/or regulatory experience and experience with Government Program products is required

• Previous experience in corporate compliance, delegation management, internal or external audit, or other assurance function is strongly preferred

Competencies, Knowledge and Skills:

• Strong familiarity with government-funded healthcare programs, including Medicaid, Marketplace, and Medicare, and the compliance standards imposed upon First Tier, Downstream and Related (FDR) entities

• Advanced ability to perform data analysis to produce meaningful insight and drive appropriate action

• Familiarity with healthcare operations and/or clinical concepts, practices and procedures

• Demonstrated understanding of compliance and regulatory fundamentals specifically related to managed care and government programs (CMS/HHS/DOI/Medicaid)

• Knowledge of internal and external audit functions and procedures

• Ability to conduct research and analysis of Federal, State, and relevant industry regulatory and enforcement

• Advanced ability to directly interact with Regulators

• Demonstrated expert level professional written and verbal communication…