Medicare Compliance Analyst

4 weeks ago

Chicago, United States Blue Cross Blue Shield companies Full time

Job Description Summary

This position enacts, monitors, and operationalizes multiple components of the FEP Medicare Prescription Drug Program.

Responsibilities include but are not limited to:

Act as liaison with third party compliance help line vendor; investigate potential compliance issues. Develop internal training programs to ensure compliance with regulatory requirements.

Support Medicare Compliance Officer by: maintaining current CMS policies; ensure various HHS contract requirements met, including the training/tracking of all new and current applicable employees and FEP BOM members; monitoring, investigation, and resolution of any member ethics complaints/allegations; completing all required internal/external reporting requirements; ensure monthly screening of employees, FEP BOM members, and applicable FDRs is completed and discrepancies resolved.

  • Gather relevant data and Key Performance Indicators for compliance reports and dashboards, and prepare reports based on established reporting metrics for the group.
  • Develop and update Standard Operating Policies and Procedures (SOP) for review processes and compliance. Educate stakeholders on these SOPs.
  • Conduct risk assessments and identify potential non-compliance vulnerabilities and make practical business recommendations to correct non-compliance or improve insufficient processes.

Required Education, Certifications and Experience

  • Bachelors Degree

  • Requires a minimum of five (5) years of relevant compliance experience in a healthcare or managed care environment.

  • Requires a minimum of three (3) years experience in the interpretation and application of federal and state regulations, policies and procedures, and ethical principles related to healthcare compliance.

  • Knowledge of the sources of legal and regulatory requirements relevant to state and federal requirements.

  • Knowledge of the Federal and State regulatory environment in the health insurance industry, with emphasis on CMS Medicare/Part D federal mandates,

  • Understanding of best practice internal ethics and compliance programs.

  • Excellent at organizing, managing, and handling competing projects with a proven ability to meet tight deadlines in a fast-paced environment.

  • Skilled at managing a high volume of work with changing priorities and frequent interruptions while maintaining the ability to work cooperatively with a positive attitude.

  • Written and oral communication.

  • Facilitation, active listening, and presentation skills.

  • Critical thinking skills and the ability to apply an analytical approach to regulatory research and issue remediation.

  • Persuasion/negotiation and interpersonal relationship skills and the ability to effectively interact and collaborate with individuals at all levels within the organization.

  • Problem solving acumen. Ability to identify potential noncompliance issues, obtain information to clarify and describe issue, exercise sound decision-making, resolve problems using appropriate risk treatment, and leverage appropriate escalation pathways.

  • High degree of discretion in dealing with the confidentiality of all compliance-related issues.

Preferred Education, Certifications and Experience

  • Compliance/legal, business operations preferred.

  • Certified Compliance & Ethics Professional Certification (CCEP) - Compliance Certification Board.

  • Certified in Healthcare Compliance (CHC) - Compliance Certification Board.

  • Leadership Professional in Ethics & Compliance (LPEC) - Ethics and Compliance Institute.


People Management No

#LI-Hybrid

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