Job Details

Compliance Analyst

The compliance analyst for the Grievance & Appeals (G&A) department plays a key support role in ensuring the department maintains compliance with regulatory, accreditation, and internal standards. Under the direction of the G&A Compliance Manager, this role is responsible for assisting with policy and the procedure maintenance, audit preparation and support, and oversight of delegated entities. The compliance analyst also plays a critical role in identifying process and quality improvement opportunities through data analysis and trending of grievance and appeal cases. This is a dynamic and multifaceted position that supports various compliance activities to maintain organizational readiness for internal audits, external reviews - such as Centers for Medicare & Medicaid Services (CMS), California Department of Health Care Services (DHCS), and National Committee for Quality Assurance (NCQA), and delegate oversight.

Responsibilities

Analyzes G&A data to identify trends, root causes, and opportunities for process improvement. Develops actionable insights based on data analysis to improve member satisfaction, quality of care, quality of service, and operational efficiency. Supports the Compliance Manager in preparing and compiling monthly and quarterly reports on department performance, trends, and key metrics. Assists with regulatory reporting to state and national agencies, ensuring accuracy and timeliness. Collaborates with reporting analysts to review and validate data used for regulatory and internal reports. Assists in the preparation and coordination of internal and external audits, including gathering documentation and conducting pre-audit activities. Collaborate with the Compliance Manager to ensure department operations remain in compliance with CMS, DHCS and NCQA requirements. Monitors grievance trends and collaborates with leadership to propose improvements to department processes. Reviews and analyzes reports from delegated entities to ensure compliance with grievance and appeals processes. Participates in the annual audit of delegated entities and assists with follow-up actions as needed. Supports quality improvement initiatives by identifying areas for operational enhancements based on data analysis.

Collaborates with the Compliance Manager on special projects related to audits, reporting, and regulatory compliance. Maintains accurate records and documentation for all regulatory, audit, and compliance-related activities. Other duties as assigned.

Qualifications

Education and Experience

Bachelor's degree in Healthcare Administration, Business Administration, Public Health, Data Science, or related field; 3-4 years of experience in the healthcare or managed care, with a focus on grievance and appeals, compliance, or regulatory reporting preferred. Experience with Medi-Cal, DHCS, NCQA, CMS, or other regulatory healthcare environment preferred. An equivalent combination of education and experience may be considered.

Special Skills, Licenses and Certifications

Working knowledge of Medi-Cal, CMS, DHCS and/or NCQA regulations and standards. Highly proficient in applicable business software applications including PC usage, Microsoft Word, PowerPoint, Excel, and typing speed of 40 wpm. Valid California Driver's License and proof of current automobile insurance compliant with Partnership's policies are required to operate a vehicle and travel for company business.

Performance Based Competencies

Excellent oral and written communication skills. Strong analytical and problem-solving skills with the ability to interpret data and trends. Excellent organizational skills with the ability to prioritize assignments, maintain effective filing systems, and meet deadlines. Ability to work under minimal supervision and exercise independent judgment. Diplomacy and tact in handling sensitive information regarding personnel affairs as required. Ability to interact with executives and vendors effectively, handling all assignments with efficiency. Must be able to handle multiple tasks and meet deadlines. Excellent judgment. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and deadlines. Strong organizational skills required.

Work Environment And Physical Demands

Ability to use a computer keyboard. Ability to prioritize workload and initiate action to acquire needed information from professionals by phone. Ability to function effectively with frequent interruptions and direction from multiple team members. More than 70% of work time is spent in front of a computer monitor. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs. Some travel required (up to 15%) including occasional overnight.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan's policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$93,690.86 - $117,113.58

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.