Senior Compliance Analyst

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

We are currently hiring a Senior Compliance Analyst to join our team

Must reside in CA - Remote

Join our team as our new Sr. Compliance Analyst with Health Plan of San Joaquin

What You Will Be Doing:

Under general supervision, responsible for providing decision support and insightful guidance, and completing complex fraud, waste, and abuse (FWA) modeling, forecasting and analysis. Work is varied and moderately complex and requires a moderate degree of discretion and independent judgment.

The Senior Compliance Analyst has advanced knowledge of the job area and technical systems and practices, and advanced technical skills and reporting abilities.

Jobs in the Data Analyst family are responsible for executing analyses that support and advance business strategy, consistent with internal and external requirements. Jobs will examine, manipulate, and interpret HPSJ’s data with the purpose of drawing conclusions about that information. Activities include: identifying areas of investigation, collecting, analyzing and interpreting data, spotting trends, and writing reports and recommendations for internal and/or external stakeholders.

Hybrid – to attend quarterly onsite meetings; remote.

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

Essential Functions:

• Identifies, monitors, queries, analyzes, and interprets FWA trends in data to identify trends, variances and other insights related to FWA for investigation and planning purposes.
• Analyzes and investigates suspected FWA and Privacy incidents for root cause, trends and tracks data to translate findings and develop processes for improvement or investigation.
• Proactively identifies potential data and analytical needs to support management and performance monitoring requirements.  
• Develops and maintains the FWA risk assessment plan, in close collaboration with Compliance management and internal stakeholders.
• Compiles, develops and submits complex reports with written summaries and recommendations to management.  
• Conducts research and analysis on contractual and regulatory requirements with respect to HPSJ and delegated vendors, and providers.
• Collaborates with external and internal stakeholders to maintain the availability, validity and integrity of data sources.  
• Maintains appropriate and required data, records, and other operational and regulatory report documentation. 
• Supports internal and external audits, and assists in the preparation of recommendations, responses, and reports. 
• Maintains the compliance FWA audit program, including schedules, standards, processes, reports and tools in close collaboration with Compliance management.
• Identifies, proposes and implements process improvements. 

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• In-depth knowledge of federal and state regulations and standards, including False Claims Act, Medi-Cal and DMHC/DHCS as they relate to compliance in health care.
• In-depth knowledge of managed care health plan functions and interactions as they relate to compliance.
• In- depth knowledge of ICD-10, CPT/HCPCS codes and modifiers, coding guidelines, medical terminology and industry standard payment practices.
• Data accuracy and process: Ability to conduct accurate analysis validation processes to ensure data accuracy and reliability and drive data decisions. 
• Synthesizing and Analytical Skills: Applies knowledge of various analytical techniques to boil down multiple, related issues of varying complexity to their essential elements and communicate trends, advice and recommendations in terms easily understood. 
• Data Visualization: Implements contemporary techniques, dynamic visual displays with illustrative and interactive graphics to present patterns, trends, analytical insights from data or new concepts for the target audience. 
• Problem-solving Approach: approaches a problem by using a logical, systematic, sequential approach. 
• Business Knowledge:   Ability to understand the impact of operational areas on financials in a Medi-Cal environment. 
• Data Sourcing and Mining: Identifies, sources, extracts and validates a variety of identified data to provide integrated information leading to accurate and timely decision making and planning; chooses appropriate data sources.
• Requirements Gathering: Identifies, scopes and documents moderately complex requirements and priorities through information gathering, probing questions, and analysis as well as clarification of the solutions, initiatives and programs. 
• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Time management: Uses time effectively and efficiently; values time; concentrates his/her efforts on the more important priorities; can attend to a broader range of activities; meets deadlines.
• Strong problem-solving skills, with the ability to identify and resolve problems of moderate complexity.
• Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
• Strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of HPSJ and explain complex information.
• Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.
• Intermediate project management skills, with ability to lead department and cross-functional projects to successful conclusion.
• Strong prioritization, planning, and organizing skills, with the ability to work consistently with strategic goals to identify priority activities. 
• Strong leadership skills, with the ability to influence without authority, establish direction, build alliances and motivate others.
• Commitment to and ability to facilitate the adoption of HPSJ’s strategy, vision, mission and values.
• Advanced skills in Excel, including ability to create complex formulas, pivot tables, data tables, simulations and solvers. 
• Advanced knowledge of data query (Sequel) analysis tools (Excel, Access, Tableau, PowerBI, or etc…) and techniques, with ability to performance analyze and interpret data.
• Intermediate skills in Word, Power Point, Visio and Project.
• Ability to speak and be understood in English. 
• Ability to treat confidential information with appropriate discretion. 

What You Have:

Education and Experience

Required

• Bachelor’s Degree; and
• At least four years of experience reading, analyzing and interpreting State and Federal laws, rules and regulations; or
• At least four years of experience in conducting, data analysis, investigating, or coding; and
• Experience working in Medi-Cal managed care operations; or
• Equivalent combination of education and experience.

Preferred

• Experience with SQL
• Experience working in a special investigation unit as an analyst or investigator.

Licenses, Certifications

Required

• None

Preferred

• Accredited Healthcare Fraud Investigator
• Certified Professional Coder (CPC)

What You Will Get:

HPSJ Perks:

• Competitive salary
• Robust and affordable health/dental/vision with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics, or is associated with anyone who has or is perceived to have these characteristics.

Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.