Job Summary:
The Compliance Business Analyst III is a professional compliance role responsible for supporting the Compliance Detection Team by focusing on data analysis activities for proactive auditing and monitoring activities. 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 internal compliance audit and monitoring, 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 work plan, and other compliance activities
- 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 compliance 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
- 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
- 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
- Responsible for data quality and verification, data delivery, change management processes and enforcement of data standards for Detection Activities
- Identify and communicate irregular trends, recommend possible improvement opportunities, and relay information to management to be researched, when necessary
- Lead and conduct data analysis on Detection Activities to identify trends, anomalies or issues related to managed care compliance or operational concerns
- Knowledgeable or proficient with statistics, and comfortable with ambiguity and fluid priorities
- Perform any other job-related instructions, as requested
Education and Experience:
- Bachelor’s Degree in Mathematics, Economics, Business or related field or equivalent years of relevant work experience is required
- Advanced degree in Business, Mathematics or Law preferred
- Five (5) years of experience with healthcare analytics required (health plan preferred)
- Three (3) years regulatory experience in Government Programs required, with specific understanding of regulatory requirements in Medicaid, Marketplace, or Long term cares support services.
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
- Proficient in MS Excel, PowerPoint and Word
- Proficient in SAS or SQL
- Exceptional analytical, problem solving and critical thinking skills
- Ability to work collaboratively with all levels of management
- Ability to manage multiple priorities within a dynamic environment
- Mature written and verbal communications skills
- Knowledge of managed care operations and finance
- Knowledge of fee for service and value based provider reimbursement methods
- Knowledge of the fundamentals of pharmacy benefit management and pricing
- Knowledge of healthcare quality programs and measures (e.g. CMS, HEDIS, NCQA, AHRQ)
- Data analysis ability to produce meaningful insight and drive appropriate action
- Proven ability to effectively manage work through prioritization, preparing, effective scheduling, leveraging resources and maintaining focus
- Strong decision making and problem-solving skills
- Demonstrated success in working in a matrixed environment
- Detail orientated with focus on maintaining accurate information in tools as required
- Time management skills including creation and maintenance of project timelines
Licensure and Certification:
- Certified in HealthCare Compliance (CHC) is preferred
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$79,800.00 - $127,600.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.