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Corporate Compliance Analyst

2 months ago

Brooklyn, New York, United States MetroPlus Health Plan Full time
Corporate Compliance Analyst

Job Ref: 110826

Category: Professional

Department: OFFICE CORPORATE COMPLIANCE

Location: New York, NY

Job Type: Regular

Employment Type: Full-Time

Hire In Rate: $90,000.00

Salary Range: $90,000 - $100,000.00

Empower. Unite. Care.

MetroPlusHealth is dedicated to empowering New Yorkers by fostering community through care. We believe that healthcare is a right, not a privilege. If you possess compassion and a collaborative spirit, consider working with us. You can take pride in your contributions every day.

About NYC Health + Hospitals

MetroPlusHealth delivers top-quality healthcare services to residents across various boroughs through a comprehensive array of products, including New York State Medicaid Managed Care, Medicare, Child Health Plus, and more. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network encompasses over 27,000 primary care providers, specialists, and participating clinics. For over 30 years, MetroPlus has focused on building strong relationships with its members and providers to help New Yorkers achieve their healthiest lives.

Position Overview

The Corporate Compliance Analyst reports to the Manager of Corporate Compliance. This role supports the oversight and management of Corporate Compliance activities, including addressing inquiries and responding to compliance-related questions. The Corporate Compliance Analyst is tasked with investigating allegations of potential fraud, waste, and abuse, as well as reports of non-compliance. Allegations may encompass provider fraud, member fraud, and broker/sales agent misconduct.

Job Description Conduct initial screenings, timely investigations, and triaging of compliance matters, including allegations of fraud, waste, and abuse. Ensure thorough investigations of alleged compliance violations, including documentation collection, data analysis, and interviews.Review and assess coding on claims data and medical documentation for accuracy related to fraud, waste, and abuse investigations.Prepare concise final investigation reports. Essential to this role is the ability to track and trend emerging issues and collaborate with the Manager to develop organizational responses for systemic issues.Create, review, and submit internal and external reports as required, engaging with leadership and vendors to compile necessary information.Draft, submit, and track referrals of substantiated or suspicious fraud, waste, and abuse cases to regulators.Review relevant memos from the Fraud Investigations Group and ensure appropriate actions are taken by internal business areas.Collaborate with business areas to initiate and complete appropriate disciplinary and corrective actions.Assist in managing relationships with the Special Investigations Unit, participating in monthly meetings, ensuring collaboration, and identifying improvement opportunities.Support the development of the annual risk assessment and implementation of the annual work plan.Stay informed on emerging topics and issues impacting corporate compliance at the State and Federal levels, ensuring proper implementation across departments.Assist the Manager of Corporate Compliance with any required regulatory reporting.Perform other duties as assigned or requested. Minimum Qualifications Bachelor's Degree required;5 years of experience in compliance, privacy, regulatory affairs, or related functions within a managed care organization; or a satisfactory equivalent combination of education, training, and experience.Master's Degree preferred.Coding certification or experience preferred.Understanding of claim billing codes, medical terminology, and healthcare delivery systems.Experience working with regulators on compliance audits and reporting.Experience managing complex projects and delivering timely results.Experience handling highly confidential and sensitive information.Experience developing reporting and metrics.Knowledge of Managed Care and Medicaid and Medicare programs.Proven ability to articulate regulatory requirements to achieve results.Knowledge and experience in healthcare fraud, waste, and abuse investigations.

Professional Competencies

Proficient in Microsoft products, including Excel, Word, PowerPoint, and Visio.In-depth knowledge of the managed care industry, including compliance planning and regulatory concerns.Ability to comprehend and interpret regulatory, legislative, and contractual mandates.High-level skills in leading interdepartmental projects and managing professional staff.Excellent oral, written, and presentation skills, with strong analytical capabilities.Integrity in handling confidential materials is essential.

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