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Operations Compliance Analyst, Dentaquest

4 months ago

Wellesley Hills, United States Sun Life Full time

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

**JOB SUMMARY**:
The Operations Compliance Analyst is a member of the Operations Compliance team, reporting to the Operations Compliance Manager. The role will support a range of compliance and oversight related activity for operations.

**PRIMARY JOB RESPONSIBILITIES**:
Compliance and Policy/Process Review
- Research and review federal and state regulations to determine the applicability to operations. Coordinate with Legal and Compliance, as necessary.
- Assist with the development of policies and procedures for operations, as well as the annual policy review.
- Work collaboratively with a technical writer to draft and review of RFP responses on behalf of operations, to ensure compliance with DentaQuest process and regulatory requirements.
- Work collaboratively with operations for implementation of policy and process on behalf of operations for accreditation under NCQA and URAC.
- Work collaboratively with the trainers to review training documentation for operations to ensure content is compliant with contract and regulatory requirements.
- Review CAP (corrective action plan) documentation and responses prior to submission to DentaQuest’s client(s) or regulatory entity that have been submitted by operations to ensure it addresses the contractual and regulatory requirements accurately.
- Compile documentation on behalf of operations for TPA and license filings and renewals.

Auditing
- Act as a back-up for the Operations Audit Coordinator II and the efforts relating external audits for complaints/grievances/appeal.
- Draft and review audit tools utilized by Internal Audit to conduct audit on complaints/grievance/appeal cases, to ensure content is compliant with contract terms, regulatory requirements, and DentaQuest policy and process.
- Review internal audit results for complaints/grievance/appeals and make recommendations to the Operations Compliance Manager to address compliance risks and deficiencies identified.
- Assist the Operations Correspondence & Support Supervisor with implementation activity for complaints/grievances/appeals.
- Conduct a random audit of the internal audits completed for complaints/grievances/appeals.
- Communicate all operational compliance risks to the Operations Compliance Manager, as they are identified.
- Cultivate and maintain professional relationships with both internal and external customers.
- Demonstrate a detailed understanding of requirements for operations, as listed in individual client contracts and in federal and/or state regulations.
- Demonstrate a detailed understanding of DentaQuest policies and processes for complaints/grievances/appeals and utilization management.
- Other duties as assigned

**JOB QUALIFICATIONS**:
Required Qualifications
- Bachelor’s degree in business, healthcare or related field (or equivalent work experience)
- 3 - 5 years of experience in a related healthcare field
- Proficient with general computer software including Microsoft Excel, Word and Outlook.
- Exceptional communication skills and the ability to communicate appropriately at all levels of the organization with the ability to influence others to move toward consensus. This to also include the ability to communicate appropriately with external customers, including clients and/or regulatory agencies.
- Excellent spirit for teamwork, problem-solving, communication, and decision-making skills.
- Strong situational analysis and decision making abilities.
- Excellent verbal, written, interpersonal, organizational and public speaking/communication skills. Able to effectively communicate visualizations.
- Ability to prioritize and organize multiple tasks with tight deadlines.
- Ability to manage multiple projects and priorities in a fast-paced, result-driven environment.
- Excellent independent problem solving skills
- Self-motivated and has the ability to work with little supervision and make independent decisions.
- Demonstrated track record of attention to detail.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

For applicants residing in California, please read our employee California Privacy Policy and Notice.

**Job Category**:
Compliance

**Posting End Date**:
27/06/2024