| Position Purpose: |
The Compliance Analyst provides support to the organization in evaluating the effectiveness of the Hometown Health Compliance Program and governance processes for Medicare Advantage, Medicare Parts C and D and commercial benefit plans. The Compliance Analyst captures and analyzes data used to detect trends that may indicate systemic risks to the organization requiring further review, assessment, root cause analysis, or follow-up. The Compliance Analyst will support the Compliance Program to ensure compliance with all Federal and State laws and regulations (CMS, Nevada DOI, URAC), contract provisions, accreditation standards, and internal policies/procedures. The Analyst will implement system wide initiatives, policies and processes related to the Compliance Program and be responsible for program oversight, risk assessment, reports creation, communication strategy, education/training and auditing/monitoring. This position will serve as a resource to support the Compliance team in the general development of the Compliance Program including, but not limited to, developing the Compliance Work Plan, Fraud, Waste and Abuse Plan, Communication Strategic Plan, Audit Work Plan, Compliance Committee/Board reports, Compliance policies/procedures and standard work.
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| Nature and Scope: |
This position is responsible for performing compliance audits and operational monitoring; special projects, as requested; and internal control and information systems evaluations at the direction of Senior Leadership and the Hometown Health Compliance personnel. This position must be objective and independent of the activity being reviewed. It is authorized to have free and unrestricted access to organization functions, records, property, and personnel.
The incumbent will be challenged by the following:
- General knowledge of Health Insurance, Managed Care, Benefit Design, Nevada Revised Statutes (NRS), Nevada Administrative Codes (NAC), Medicare Advantage Prescription Drug plans (MA-PD) and Federal Regulations.
- The ability to apply knowledge to recognize the existence of problems or potential problems and identify additional research to be undertaken or assistance to be obtained in the following areas: internal audit standards, procedures and techniques, clinical principles and techniques, management principles and deviations from ethical business practices, and fundamentals of business subjects.
- Knowledge of Medicare programs and CMS regulations and the ability to provide operational guidance and support for defining and documenting data validation policies and procedures, requirements for technical specifications, and data reporting skills to support specified components of Medicare Part C & Part D programs.
- Knowledge of Vendor Oversight Program to include analyzing risk assessments, performing audits, creating reports, educating and following up with the business area to ensure processes exist to demonstrate compliance with delegation and vendor oversight requirements for the Plan.
- Simultaneous action at varying stages--initiation, follow through, and completion--on a number of different projects.
- Resourceful, detail-oriented, and able to assimilate and analyze a wide variety of information, often working under deadline pressure with a variety of levels of staff.
- Coordinate projects conducted by contracted external vendor and answer questions regarding the compliance review process. Review data and reports drafted by external vendor.
- Prepare clear, concise written reports related to the review findings for internal and external reporting purposes.
- Ability to review and understand insurance benefits for all product lines.
- Demonstrate the ability to design and develop reports, documents and spreadsheets.
- The ability to communicate verbally and in writing in a way that effectively conveys project background, objectives, activities, evaluations, conclusions, and recommendations.
- Decisive and exercises good judgment under pressure.
- Excellent organization, problem solving and analytical skills.
- Ability to review, analyze and interpret regulatory requirements in a clear and concise manner.
- Strict adherence of rules and regulations for confidentiality and compliance.
- Ability to maintain effective collaborative working relationships with internal staff.
- Ability to work independently with minimal supervision.
This position does not provide patient care. |
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| The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job. |
| Minimum Qualifications: Requirements - Required and/or Preferred |
| Education: |
Must have working-level knowledge of the English language, including reading, writing and speaking English. Four-year degree from an accredited college preferred. |
| Experience: |
Minimum two years experience in compliance within the health insurance industry or health care, preferred. Experience with Medicare Advantage plans or Medicare Managed Care preferred. |
| License(s): |
None. |
| Certification(s): |
None. |
| Computer / Typing: |
Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc. Typing 35 WPM. |