ABOUT GOLD KIDNEY HEALTH PLAN:
Gold Kidney Health Plan is a newly founded Medicare Advantage health plan, will serve Medicare beneficiaries in various counties in Arizona and Florida. Our employees are passionate in providing best services to our members and healthcare providers. To learn more please visit https://goldkidney.com.
GOLD KIDNEY CORE VALUES:
Gold Kidney Health Plan is a people business. Our success depends on having the best and brightest employees and helping them attain their personal and professional goals while delivering excellence in patient care and business results. Our employees embody our culture, which is based on six core values supporting our promise to improve the quality of life of every patient every day. These core values are Patients and Partners First, Honesty and Integrity, Quality and Compliance, Collaboration, No\-Limits Mindset and Results Oriented.
PURPOSE AND SCOPE:
As a Senior Compliance Analyst, you will assist in maintaining an internal compliance program; guide special projects; provide regulatory interpretation; perform compliance reporting; and develop and implement compliance auditing and monitoring strategies. The Compliance Analyst is responsible for conducting audits of departments involved in the delivery or administration of Medicare Advantage and Medicare Part D plans for compliance with CMS and company standards, including but not limited to: Part C \& Part D program compliance, state laws and regulatory compliance, NCQA, privacy and security, detecting, preventing, and correcting fraud, waste, and abuse.
ESSENTIAL FUNCTIONS:
An individual must perform each essential function satisfactorily with or without reasonable accommodation; including, but not limited to:
1\. Understand and prioritize timeframes associated with CMS Medicare Advantage (MA) Prescription Drug Plan (PDP), federal and state regulatory submissions/reporting calendar, Compliance Toll\-Free Hotline, CMS Complaint Tracking Module (CTM) and other documents. Communicate state and federal requirements related to the plan to internal and external clients.
2\. Review and monitor new and updated laws and regulations, disseminating findings to key stakeholders accordingly. Participate and co\-chair in various compliance subcommittees and workgroups.
3\. Perform periodic compliance audits, risk assessments and conduct related ongoing compliance monitoring activities.
4\. Prepare analyses/reports based on audit results, including recommendations for corrective action; maintain records of audits and follow\-up of corrective actions.
5\. Upload State and Federal monthly, quarterly, and annual reports to secure sites while maintaining high accuracy, timeliness, and security of the data.
6\. Perform detailed examinations of audit documentation.
7\. Coordinate deliverables for internal/external audits including but not limited to CMS Full Program Audit, 1/3 Financial Audit, Bid Audit, State Examination, Part C and D CMS Reporting Data Validation and Compliance Program Effectiveness annual audit.
8\. Coordinate annual policy reviews, makes policy revisions as directed, keep policies organized, revised, and updated in compliance with regulatory and specific contract requirements.
9\. Conducts research, updates, and assists in tracking licenses.
10\. Regulations are added, removed, and changed, as such Senior Compliance Specialist must assist and stay up to date with any regulatory action relevant to healthcare.
11\. Compiles data and can put in pivot table within Excel, etc.
12\. Works well under deadlines. Ability to communicate, interact, and work well with others under pressure.
13\. Respond to external requests for information required by the organization for its regulatory filings; respond to inquiries from state and federal regulatory agencies.
14\. Assist in developing, producing and conducting compliance training programs.
15\. Assist affiliated and managed health plans in managing relationships with regulatory agencies and seeking to resolve policy issues which may negatively impact service to members.
16\. Complete other assigned tasks, as directed by Leadership.
REQUIRED SKILLS:
· Working knowledge of related federal and state laws and regulations and CMS compliance guidance.
· Ability to demonstrate strong understanding of CMS requirements and regulations related to Medicare Advantage and Medicare Part D operations and compliance.
· Ability to effectively present complex information and respond to questions from both internal and external partners.
REQUIRED WORK EXPERIENCE:
· Minimum (4\) four years’ related experience in compliance, privacy and/or regulatory affairs, legal assistant/paralegal
· Experience in health care industry in related field including understanding of regulatory, contractual, and operational responsibilities of Medicare Advantage plans and Health Maintenance Organizations
· Medicare Compliance, medical claims processing, PBM, Care Management and/or pharmacy audit experience.
· Project management experience and managing multiple high priority projects with competing deadlines including accreditation like NCQA.
· Working knowledge of laws and/or regulations in area of compliance; specifically, CMS MA/PD Program, HIPAA, FWA, NCQA and state department of insurance laws, regulations and administrative rules.
· Strong technical skills in compliance document management.
LICENSING/CERTIFICATIONS/EDUCATION REQUIREMENTS:
· Bachelor’s degree in business, finance, accounting, legal, or healthcare. In lieu of a bachelor’s degree, we will accept candidates with significant hands\-on experience in Medicare Advantage Chronic Special Needs Plans (C\-SNP).
· Certification in Healthcare Compliance (CHC) or other relevant certification(s),
REQUIRED COMPUTER SOFTWARE/EQUIPMENT USED:
· Microsoft Outlook, Excel, Word, and PowerPoint with strong Excel / data analysis skills.
· Experience with policy management tools, such as PolicyTech by Navex.
· Ability to learn required systems and capacity to automate processes.
PHYSICAL REQUIREMENTS:
· Job may require occasional lifting of objects up to twenty (20\) pounds.
EQUAL OPPORTUNITY EMPLOYER:
Our organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities who make a request for an accommodation.
Pay: $85,000\.00 \- $100,000\.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Flexible schedule
- Flexible spending account
- Health insurance
- Health savings account
- Paid time off
- Vision insurance
Work Location: Remote