[Hiring] Senior Embedded Compliance Analyst @CareFirst

Role Description

The Senior Embedded Compliance Analyst will support Corporate Compliance and its defined Compliance Program by performing compliance activities for Medicare Advantage. This position involves ensuring implementation and maintenance of the annual Compliance Workplan for Medicare Advantage while providing review and analysis of regulatory rules/guidelines, monitoring the organization's compliance performance, tracking Key Performance Indicators (KPIs)/Key Risk Indicators (KRIs), and supporting Program Integrity and Fraud, Waste, and Abuse (FWA) efforts.

• Monitors compliance performance based on a Compliance Risk Assessment to provide compliance oversight for Medicare Advantage.
• Review, analyze, and distribute regulatory rules/guidelines/contractual requirements to educate impacted CareFirst business areas and delegated entities.
• Identify and track required actions as the result of regulatory rules/guidelines/contractual requirements.
• Track and assess Key Performance and Key Risk Indicators (KPI/KRIs).
• Identify compliance risks by gathering, reviewing, and analyzing organizational data for downward trends or instances of non-compliance or potential non-compliance.
• Collaborate with business owners within Medicare Advantage to establish and monitor action plans to address remediation of compliance risks.
• Help ensure that a root cause analysis is performed to address underlying issues when an action plan is needed.
• Follow up with stakeholders to help ensure remediation efforts are on track, successful, and validate that action plans have been implemented correctly.
• Regularly monitor CAP implementation and communicate and report risks associated with identified control deficiencies to stakeholders.
• Provide reporting to the Compliance leadership, documenting CAP results and escalating risks and issues related to identification, implementation, and remediation.
• Assist with the performance of post-implementation procedures to validate performance of compliance requirements resulting from mandates, regulatory and contractual changes, systems, or partner implementations for Medicare Advantage.
• Perform investigations, research, and due diligence to address compliance incidents, events, research, inquiries, and concerns from leadership for Medicare Advantage.
• Perform assessments to identify compliance risks preceding or in parallel to compliance incidents, events, company initiatives.
• Provide professionally written and audit-appropriate responses to the originating party, ensuring questions are answered and customer needs are effectively served within designated time frames while respecting the privacy needs of members.
• Collaborate with Corporate Ethics & Compliance on Code of Conduct and Third-Party Code of Conduct to ensure compliance.
• Support and drive the continued maturity of CareFirst compliance through ongoing education, development of compliance tools, compliance initiatives, and collaboration with other compliance risk functions (e.g., Internal Audit, Executive Inquiry, Privacy) to respond to compliance incidents, gaps, and identified risks.
• Supports the development, implementation, and maintenance of written policies and procedures for Medicare Advantage.
• Collaborate and contribute to standards of conduct.

Qualifications

• Bachelor's Degree in Business Administration, Healthcare Compliance or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
• 5 years experience in health insurance industry, managed care and government programs, health insurance compliance programs, or related fields.
• Healthcare Compliance certification(s) preferred.
• Experience in CMS programs (Medicare or Medicaid, project management, business process analysis, workflow, and task analysis) preferred.
• Process Improvement Systems training in Six Sigma, Lean, or other Business Process Improvement tools preferred.

Requirements

• Excellent interpersonal skills with ability to build consensus and agreement and bring resolution to contentious issues and entrenched interests.
• Ability to present and discuss regulatory compliance goals in a way that establishes rapport, persuades others, and gains commitment.
• Ability to research complex issues, interpret regulations and regulatory rules/guidance, and exhibit sound judgment in determining a recommendation or solution to a problem.
• Proficient in Word, Advanced Excel, and database management and related software applications.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
• Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Benefits

• Comprehensive benefits package.
• Various incentive programs/plans.
• 401k contribution programs/plans (subject to eligibility requirements).

Company Description

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.