Insurance Compliance Analyst

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The Insurance Compliance Analyst will play a vital role as part of a growing, fast-paced team developing compliance programming and program integrity plans to support Peak Health products including Medicare Parts C and D, third-party administration, and other commercial health plan products. The ideal candidate will understand an effective health plan compliance program, have excellent analytical skills, and the ability to effectively communicate compliance requirements to various stakeholders within the organization.
The Analyst is responsible for assisting in compliance activities including monitoring, auditing, investigating, and updating policy and procedures. In addition, the analyst will assist in with vendor oversight activities. The Analyst is also expected to improve existing processes, lead analysis, and provide cross-functional compliance support to business areas.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in healthcare administration, compliance, paralegal studies, business administration, or related field

EXPERIENCE:

1. Two (2) years of health care compliance experience

2. Two (2) years of health care regulatory experience

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Certified in Healthcare Compliance (CHC)

EXPERIENCE:

1. Understanding of compliance requirements for Medicare, Medicaid, and Commercial Lines of Business

2. CPA or audit and investigation experience

3. Vendor activity management a plus

4. Analyzing and communicating regulatory requirements

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Participate in and support compliance program activities including monitoring, investigations, exclusion screenings, policy preparation, communications, and training.

2. Lead the compilation, tracking and reporting of deliverables; review deliverables for accuracy and facilitate corrections.

3. Assist with vendor activities, including documentation of all pre- and annual delegate oversight and on-going vendor oversight activities.

4. Assist with compliance audits and related activities, including tracking documentation, coordination of interviews, and support the preparation of final reports.

5. Provide analysis, interpretation, training, and education related to requirements as needed to ensure understanding and effective implementation of compliance requirements.

6. Support operational partnerships to ensure compliance with applicable rules and regulations, while supporting a positive member experience.

7. Develop and implement process improvement and automation for Compliance Department.

8. Investigate issues with effective research, root cause analysis, and gap analysis for effective remediation and corrective action management.

9. Maintain and enhance current knowledge of compliance and best practices through attendance of meetings and seminars, study of reference materials, and updates to compliance rules and regulations. Review newsletters, journals, best practices, updates to compliance rules and regulations, etc.

10. Utilizes Windows suite and document management program to perform compliance oversight and documentation.

11. Assist with various projects as assigned.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to stand and walk short distances for eight or more hours.

2. Frequent bending, stooping, or stretching.

3. Ability to lift 30 pounds and push 50 pounds.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

2. Some travel may be required to offsite meetings.

SKILLS AND ABILITIES:

1. Advanced organizational and project management skills.

2. Outstanding verbal and written communication skills.

3. Demonstrated understanding of Compliance Program fundamentals including performing monitoring and audits, creating reports, educating and following up with the business area to ensure processes exist to demonstrate compliance with Federal and State requirements.

4. Ability to effectively manage multiple priorities and deadlines through prioritization, effective scheduling, and maintaining focus.

5. Strong analytical and problem-solving skills.

6. Ability to perform research and analysis and summarize information. 

7. Ability to handle and maintain confidential information.

8. Ability to work independently and cooperatively as a team member.

9. Ability to understand contract terms and conditions.

10. Strong written and oral communication skills.

11. Ability to work in an ambiguous, fast-paced and rapidly changing environment.

12. Extensive working knowledge of Microsoft Office applications (Excel and Sharepoint).

Additional Job Description:

HYBRID (Morgantown, WV)

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

500 PHH Administration