Sr. Medicare Compliance Analyst

Job Description

Sr. Medicare Compliance Analyst

Lead II - Business Analysis

Who We Are

Advantasure is a growing company and a member of the UST HealthProof family, Advantasure champions innovative solutions with an eye on the future—providing health plans with the flexibility to adapt to a changing regulatory environment and evolving business needs. Leveraging the industry’s leading experts in government-sponsored health plans, Advantasure offers solutions for administrative cost management, quality patient outcomes and experiences, enrollment growth, risk adjustment and quality and provider engagement initiatives.

We achieve this mission together through teamwork, communication, collaboration, and focus. Our employees are our greatest assets, and we invite you to apply to be a part of our journey toward making a difference in healthcare in the United States. **

You Are**

The Sr. Medicare Compliance Analyst position is responsible for a variety of functions, including but not limited to the collection and review of data universes for accuracy to protocols, data analysis to identify risks and trends, conducting complex regulatory research, providing guidance to business areas related to regulatory requirements, completing departmental reporting and project related tasks accurately and within all required timeframes. Additionally, the Sr. Analyst will maintain a working knowledge of CMS regulations related to Medicare operations, performing routine compliance monitoring and reporting, creating/ updating policies and processes as needed, and supporting audit and corrective action-related initiatives. **

The Opportunity**

• Monitor changes to CMS regulations and guidance, perform complex regulatory and sub-regulatory research and analysis including monitoring changes to CMS regulations and guidance, providing comprehensive summaries and an impact assessment to business stakeholders on those changes, and ensuring implementation of any necessary process changes.
• Conduct an extensive and thorough analysis of regulatory guidance from various sources such as Medicare Managed Care Manuals, Prescription Drug Benefit Manuals, HPMS memorandums, CMS Transmittals, and Federal Register publications, and provide interpretation to internal/ external stakeholders as necessary.
• Develop and implement compliance tools designed to measure performance against applicable regulatory and contractual requirements to ensure compliance with CMS regulations governing functions.
• Serve as liaison between clients and internal business partners.
• Research, analyze, and interpret new or revised Medicare rules and regulations, and identify impact to business areas and delegated vendors.
• Conduct routine monitoring and/or focused audit and communicate findings to impacted business areas along with follow-up resolution.
• Receive, monitor, and resolve CTMs and document all actions taken in HPMS in accordance with the CTM Standard Operating Procedures (SOP).
• Lead assigned projects from planning and scoping to delivering results to key stakeholders.
• Support addressing concerns related to compliance, privacy, fraud, waste, and abuse, client contract compliance, and delegation oversight.
• Maintain accurate and comprehensive documentation of compliance activities to meet the requirements of clients and regulatory agencies.
• Support operational areas by reviewing their P&Ps to ensure processes align with regulatory requirements.
• Conduct complex investigations, document findings, and ensure corrective actions are implemented.
• Develop and monitor metrics to measure regulatory compliance within business areas.
• Identify risks and coordinate departmental monitoring, auditing, and investigation of potential non-compliance to applicable regulations and policies.
• Effectively communicate compliance issues to all levels of management and staff personnel.
• Ensure risks are escalated and appropriately addressed.
• Provide support with coordinating CMS audit and/or client-initiated audit deliverables in collaboration with other Medicare Compliance team members to ensure timely and accurate submissions.
• Provide support during internal audits, and client-initiated audits.
• Executes compliance procedures and enforces policy governance across the organization to validate that regulatory reporting requirements are met and that business operations are aligned with expectations of applicable regulatory guidance.
• Serves as subject matter expert within Compliance and develops solutions to highly complex compliance problems.
• Lead project management efforts for highly sensitive Compliance initiatives
• Mentor less experienced staff as necessary.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. **

What You Need**

• Bachelors degree in Healthcare Administration, Public Health, Business Administration, Population Health, Health Informatics, or a related field.
• Compliance professional certifications are preferred but not required.
• Seven+ years experience in a Medicare Advantage/ Medicare Part D environment, including experience in the areas of Medicare operations and compliance.
• Preference is given to applicants whose experience includes a combination of Medicare Compliance, Medicare Product, and Medicare Part C and D Operations (e.g., enrollment, marketing communications, premium billing, appeals and grievances, claims, utilization management, quality, customer service, STARs, risk adjustment, etc.).
• Strong preference is given to applicants with Medicare risk adjustment coding experience as an auditor/coder within a health plan, who are certified in medical auditing, healthcare compliance, and/or current or former licensed clinicians (e.g., RN).
• Ability to work independently, within a team environment, and communicate effectively with employees at all levels.
• Ability to synthesize large volumes of data and package them to present to others in a clear and concise manner.
• Excellent analytical, planning, problem-solving, verbal, and written skills to communicate complex ideas.
• Ability to correctly assess what needs to be done, perform job responsibilities, and carry out day-to-day activities with minimal supervision.
• Ability to generate original thoughts and ideas while also being aware of the needs and perspectives of others.
• Must be highly organized, analytical, and detail-oriented.
• Excellent interpersonal skills.
• Must be an effective public speaker, presenter, and communicator with diplomacy and tact.
• Strong oral and written communication skills.
• Strong facilitation, collaboration, and teamwork skills with the ability to build cross-functional partnerships to drive results.
• Must be able to facilitate meetings and achieve consensus regarding work plans and responsibilities.
• Demonstrate ability to understand and interpret complex regulations.
• Working experience with PC-based applications such as Excel, PowerPoint, and Word.
• Excellent time management skills.
• Strong conflict resolution skills.
• Process and project management ability.

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by local law, UST provides a reasonable range of compensation for roles that may be hired in California, Colorado, New York, or Washington as set forth below. **

Role Location: Remote

Compensation Range:** $67,700 - $98,000

Our full-time, regular associates are eligible for 401K matching, and vacation accrual and are covered from day 1 for paid sick time, healthcare, dental, vision, life, and disability insurance benefits. **

What We Believe**

We’re proud to embrace the same values that have shaped UST and its subsidiaries since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone to champion diversity and inclusion and place people at the center of everything we do. **

Humility**

We will listen, learn, be empathetic and help selflessly in our interactions with everyone. **

Humanity**

Through business, we will better the lives of those less fortunate than ourselves. **

Integrity**

We honor our commitments and act with responsibility in all our relationships. **

Equal Employment Opportunity Statement**

UST is an Equal Opportunity Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

UST reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

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