The Compliance Analyst is responsible for overseeing and maintaining the organization’s compliance with all applicable federal, state, and local regulations governing PACE of the Triad. Responsibilities include managing the Corporate Compliance Program, detecting and preventing fraud, waste, and abuse, ensuring adherence to HIPAA, and conducting internal investigations and audits. The Compliance Analyst reports to the Director of Quality and Compliance and governing board. This position has an independent oversight role. Additionally, this position is responsible for seeking and maintaining the Provider Network for all locations.
Education/Special Training/Experience:
Bachelor’s degree in healthcare administration, law, or related fields. Minimum 3-5 years in healthcare compliance; experience in PACE, long-term care, or Medicare/Medicaid managed care preferred. Strong knowledge of CMS PACE regulations, HIPAA, and fraud prevention guidelines. Experience conducting internal investigations and managing compliance audits. Proven experience in compliance, audit, or risk management, ideally within the healthcare sector or government.
- Ability to navigate federal and state requirements simultaneously.
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Ability to identify pertinent policy issues; develop strategies, solutions, and procedures.
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Able to foster a culture of compliance, quality, and continuous improvement.
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Able to work independently and as an effective member of a team.
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Able to maintain confidentiality.
- Excellent analytical, problem-solving, attention-to-detail and follow through skills.
- Exceptional written and verbal communication, with ability to explain complex topics to diverse audiences.
- Proficiency with data analysis and reporting and visualization tools.
Essential Job Functions
Corporate Compliance Program: Develop and oversee the organization’s Corporate Compliance Program in accordance with 42 CFR Part 460 Programs of All-Inclusive Care for the Elderly and 42 CFR 423.504(b) Conditions necessary to contract as a Part D plan sponsor, state regulations, and OIG guidance.
Serve as the organization’s Privacy Officer designee and oversee HIPAA compliance.
Develop, review, and update policies and procedures related to compliance.
Lead internal investigations into compliance concerns, report findings, and implement corrective actions.
Report on organization’s grievance and appeal tracking system; analyze trends and report results to quality improvement and leadership.
Coordinate required staff training on CMS Federal Regulations, State regulation Clinical 3B, FWA, HIPAA, and Code of Conduct.
Serve as primary liaison with regulatory bodies during audits, investigations, or surveys.
Ensure timely reporting of any potential non-compliance to CMS, state agencies, and leadership.
Provide quarterly (or more frequent) compliance reports to the board or designated compliance committee.
Facilitate agency compliance committee.
Collaborate with Risk Management and Quality on risk mitigation, trend analysis, and shared process improvements.
Monitor various key performance indicators including but not limited to percentage of completed regulatory audits, FWA training completions, HIPAA breach incident rates, Timeliness of corrective actions, Regulatory citations/deficiencies.
Develop joint SOP with Leadership for incidents, audits, and reporting workflows.
Responsible for the Organization’s Provider Network. This includes seeking new Providers, monitoring existing Providers and collaborating with leadership on the evaluation of the Provider Network.
Other duties as assigned.
