Resp & Qualifications
The Lead Regulatory Compliance Analyst will conduct independent analysis for the most complicated, high level regulatory inquiries and provide interpretation of regulatory rules and guidelines to demonstrate compliance with state and federal requirements. The incumbent will audit internal controls to identify high risk exposure, will provide recommendations to business areas and will track implementation of remedial solutions. The Lead Regulatory Compliance Analyst will perform a variety of tasks to assist with the design and implementation of company policies and/or be responsible for reporting as required.
Lead analyst with extensive external contact with Regulatory Agency Investigators. Provide interpretation of regulations and regulatory rules/guidelines to ensure compliance with state and federal requirements. Research, resolve and respond to written and telephone inquiries received. Coordinate with internal and external parties to ensure accurate information is obtained. Review and analyze provided data and information. Provide detailed professionally written responses to originating party, ensuring all questions are answered and customer needs are effectively served within designated time frames while ensuring privacy needs of members are respected. Strategies with Legal and Compliance as needed to identify the best response to the complaint. Subject matter expert for business processes and related systems. Maintain database of Executive Inquiry cases.
Review complex business processes, systems, workflows, SOPs and P&Ps to identify, document, and elevate the presence of risks and trends within, that may be non-compliant with contracts and or statutory requirements especially in the claims processing, enrollment and service arenas – all jurisdictions, all products, all processing platforms to include our subsidiaries and vendors. Keeps abreast of emerging issues and developments that have direct impact on the company. Ensure compliance with internal policies, procedures, and State & Federal Laws and Regulations. Provide input to business area(s) on compliance-related issues by providing direction regarding existing policies and procedures to satisfy regulatory requirements. Actively develops, implements and utilizes appropriate systems and management tools, such as , metrics, reports and investigative/audit findings to assist with ensuring appropriate data is gathered and analyzed to identify current state, trends, areas of risk within the corporation regarding compliance and ethics. Develop and present management reports as needed on findings.
Provide research, investigative and analytic support on the resolution of regulatory complaints or other escalated complaints as well as oversight of their resolution resulting from sources in which deficiencies and/or risks have been identified in these cases. Track and provide monthly reports on trends in regulatory-related complaints or other compliance-related operational incidents that identifies potential operational issues. Provides recommendations to business areas regarding the implementation of existing policies and procedures to ensure regulatory compliance. Leads in the analysis of existing business processes and systems to identify and document risks and trends within systems and processes that may not be compliant with regulatory, state or contractual requirements. Actively participates in implementation/corrective workgroups to ensure remedial solutions address the identified risks and appropriate steps are planned.
Maintain an awareness of corporate compliance and ethics practices, developments and trends, notably within a health care environment. Review, analyze and prepare detailed documentation for support of legal action pertaining to the organization indemnity business, ensuring that all appropriate materials, related claims, contracts, payment vouchers are included. Prepares investigative information and reports by collecting, analyzing, and summarizing data and trends; presents recommendations. Appears as required to testify at legal proceedings on behalf of CareFirst.
Provide training and mentoring to Regulatory Compliance Analysts in the performance of assigned regulatory complaint assessment activities and other activities related to business unit compliance for escalated issues. Monitors and tests the effectiveness of remedial solutions to identified risks.
Education Level: Bachelor's Degree
Experience: 8 years in a Compliance, Legal Regulatory or senior level Customer Service role. In lieu of a bachelor’s degree, an additional 5 years of relevant work experience is required in addition to the required work experience.
Knowledge, Skills and Abilities (KSAs)
Salary Range: $78,120 - $155,155
Salary Range Disclaimer
Salary will be based on education, location, experience, certifications, etc. In addition to your salary, CareFirst offers benefits such as a comprehensive benefits package, incentive and recognition programs, and 401k contribution (all benefits are subject to eligibility requirements).
Department: (Compliance Performance Office)
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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