Sr Analyst, Compliance (Remote - PST Preferred)

Job Description

JOB SUMMARY:

The Sr Analyst, Compliance ensures compliance related to laws, regulations, and industry codes affecting Managed Care, including but not limited to Medicare Advantage, Prescription Drug Plan, and Duals businesses, including Centers for Medicare & Medicaid Services (CMS) and Department of Managed Health Care (DMHC) regulations, False Claims Act, Anti-Kickback Statue, OIG guidance, and the Knox Keene and HIPAA/HITECH, CMIA, and CCPA Acts. Provides guidance, support and advice regarding the Compliance Program. Maintains, reviews, and updates appropriate policies and procedures. Develops and conducts any necessary training, leads and executes corrective action plans, and monitors the business operations to ensure compliance with all applicable laws, regulations and Molina’s Compliance Program.

ESSENTIAL JOB DUTIES:

• Comprehensive start-to-finish review of new regulations and guidance (Final Rule, Readiness Checklist, HPMS Memos) to ensure proper implementation, incorporation of operational/health plan/FDR (first tier, downstream, and related entity) feedback, monitoring, policies & procedures, training is tracked.
• Partnering with business (Internal Operations, Health Plan, & FDRs) throughout implementation and operationalization to ensure comprehensive compliance oversight, guidance, and proactively identify risk.
• Leading workgroups to perform RACIs on net-new processes or high-risk areas requiring additional oversight.
• Ensure comprehensive monitoring of operations beyond KPIs to verify spot checks are completed.
• Work with industry/MAPA on compliance best practices.
• Perform spot checks/audits of HPMS Memo/Final Rule operationalization.
• Liaison between Health Plan, Internal Operations, Delegation Oversight & SIU for referrals, RFI requests, investigations.
• Lead IPA (Independent Physician Association)/Health plan related investigations for “services not rendered” investigations.
• Forward disenrollment without consent allegations to gaining plan(s) for investigation.

REQUIRED QUALIFICATIONS:

• 5 years’ related compliance work experience and/or credentials
• Exceptional communication skills, including presentation capabilities, interpersonal skills and conflict resolution.
• Excellent negotiation skills with exceptional interpersonal communication and oral and written communication skills.
• Ability to maintain an independent and objective perspective.

PREFERRED QUALIFICATIONS:

• CHC (Certified in Healthcare Compliance)

Job Info

Job Identification: 2030614

Job Category: Legal, Risk, & Compliance

Posting Date: 2025-03-07T13:55:28 00:00

Job Schedule: Full time