CareFirst Careers

Lead Regulatory Compliance Analyst

Resp & Qualifications

PURPOSE:

• The Lead Regulatory Compliance Analyst will assist the Manager, Regulatory Compliance with identifying and tracking all components of the Consumer Government Programs Division Medicare/Medicaid regulatory embedded compliance program.  

• The Lead Regulatory Compliance Analyst will perform a variety of tasks to assist with the design, implementation, and execution of the Medicare/Medicaid Compliance program.  

• The Lead Regulatory Compliance Analyst position will coordinate and monitor the activities of the assigned business area(s) utilizing a risk-based approach to identify compliance risks and to assist the Medicare/Medicaid operational areas and track the implantation of remedial solutions.

 PRINCIPAL ACCOUNTABILITIES:

1.  Embedded Compliance Monitoring and Reporting

• Analyze Medicare/Medicaid operational reporting to validate business process compliance with regulatory standards.  Coordinate with operational and technical reporting functions and all relevant stakeholders.

 • Analyze operational reporting prepared for submission to federal or state regulators (such as, ODAG/CDAG reports, risk and encounter submission reports, enrollment reporting) for compliance with applicable regulatory standards.

 • Resolve all compliance issues identified through compliance monitoring activities.

 

2. Medicare/Medicaid Risk Management Program

• Coordinate Consumer Government Programs Medicare/Medicaid comprehensive risk based operational compliance assessment program to effectively test controls and track the implementation of departmental policies and procedures for compliance with all applicable regulations and regulatory guidance.

• Coordinate and perform risk assessments of identified risk areas in operations.

• Review and analyze compliance related risk assessments, reports, and other compliance related source documents for unusual activity, root cause analysis and evaluation.  Follow up with Regulatory Analysts and responsible business area(s) /individuals for explanation, discussion, resolution and appropriate action.

• Proactively assist CD Compliance management in identifying and containing compliance risks, monitoring, reporting.  

• Lead and coordinate other compliance reviews, projects related to the Medicare/Medicaid compliance risk assessment program.  

 

3.  Regulatory Framework and Business Process Risk Analysis

• Review and analyze functional area Policies and Procedures, SOPs, workflows, and systems and ensure they are in compliance and alignment with regulations and remain updated and current

• 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. 

• Review internal controls, both manual and automated, and/or management controls in each functional area to remove any risk or exposure.  

• Analyze controls for strengths and weaknesses and ensures that special focus is allocated to the specific risk areas creating the highest exposure to the Business Unit.   

•  Keeps abreast of emerging issues and developments that have direct impact on the Business Unit.

• Monitor activities of assigned areas, typically of very complex detailed nature, to ensure compliance with internal policies, procedures, and State & Federal Laws and Regulations.   

• Provide support to assigned area(s) on compliance-related issues by providing guidance regarding the implementation of existing compliance policies and procedures to satisfy regulatory requirements.  

 

4.   Compliance Incident Resolution

• Provide research, investigative and analytic support on the resolution of compliance-related member complaints or other compliance-related operational incidents as well as oversight of their resolution resulting from regulatory or other sources in which deficiencies and/or risks have been identified in these cases.

• Track provide monthly reports on trends in compliance-related member complaints or other compliance-related operational incidents that identifies potential operational issues and work with all relevant stakeholders to implement prompt corrective action.

 

5.   Regulatory Awareness and Change Implementation

• Maintain awareness of regulatory changes in Medicare/Medicaid governing laws, regulations, rules, guidance and best practices. 

• Distribute regulatory change alerts to all affected business areas. 

• Work with all relevant CareFirst stakeholders to implement regulatory changes into Medicare/Medicaid operations as required.

• Incorporate implemented regulatory changes into the Medicare/Medicaid compliance program, including operational monitoring and risk assessment programs.

• Maintain an awareness of corporate compliance and ethics practices, developments and trends, notably within a health care environment.  Consistently seeks opportunities to improve the Medicare/Medicaid operational compliance program.

• Promote an environment that supports CareFirst’s core values serving as a role model for the Medicare/Medicaid compliance program and to foster a culture of compliance and ethical behavior throughout the Consumer Government Programs Division.  

6.   External Audit Management and Governance

• Assist the Business Unit in the management and response to external audits of operations.

 • Implement process and forum to review audit findings with stakeholders. Review audit findings with appropriate management staff to ensure accuracy. Perform follow-up activities related to audits/reviews and special projects and ensure corrective action and remediation occurs. Perform internal follow-up audits on each functional group to ensure that the department has implemented corrective actions. Prepare reports on follow-up audit activities. 

 • Work with management to establish and implement corrective action plan as an outcome of any audit findings. 

 • Assist management in discharging their responsibilities by mitigating risks, safeguarding assets, identifying fraudulent activities, complying with laws and regulations directly tied to operational efficiency. 

 • Monitor, assess, and report significant matters to the Compliance Manager and the Director of Communications, Compliance, Finance, and Sales Support. 

 

RESPONSIBILITIES:

Position responsibilities include but are not limited to:

• Uses operational reporting, data analysis, and operational and compliance incident information to monitor and identify trends and potential and existing compliance risks within assigned areas regarding compliance with internal policies, procedures and State and Federal laws and regulations. 

• Actively develops, implements and utilizes appropriate systems and management tools, such as metrics, operational 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 and Consumer Government Programs Division leadership ready reports as needed on findings. 

• Provides research, support and guidance to assigned areas regarding implementation of existing policies and procedures to ensure 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 or new regulatory changes.

• Actively participates in implementation/corrective workgroups to ensure remedial solutions to address the identified risks are adopted and validate appropriate corrective actions are implemented.

• Provides training and mentoring to Regulatory Compliance Analysts in the performance of assigned risk assessment activities and other activities related to the Medicare/Medicaid embedded compliance program.

• Monitors and tests the effectiveness of remedial solutions to identified risks.

• This position does not have direct supervisory responsibility.

QUALIFICATION REQUIREMENTS:

Background/Experience:

• Minimum of 5 years cumulative working experience in one or more of the following areas is required:  (1) health plan operations or operations analysis; (2) health plan compliance programs; (3) health plan regulatory oversight or enforcement; (4) health insurance policy or analysis; or (5) related fields. 

• Minimum of 2 years cumulative working experience in one or more of the following areas is required:  (1) Medicare or Medicaid program federal or state plan compliance, regulatory oversight, or enforcement; (2) Medicaid or Medicare plan operations or plan operations analysis; (3) Medicare or Medicaid fraud, waste, and abuse prevention or investigation; or (4) Medicare or Medicaid plan audits or corrective action plan implementation or oversight. 

Experience with CareFirst plans, operations, and/or systems is preferred. 

Abilities/Skills: 

The applicant must display

  1. leadership qualities, regulatory analytical awareness, and business perspective;
  2. considerable judgment, tact, initiative, accuracy and trustworthiness; and
  3. excellent interpersonal skills with ability to build consensus and agreement and bring resolution to contentious issues and entrenched interests. 

This applicant must also display

  1. the ability to present and discuss regulatory compliance goals in a way that establishes rapport, persuades others, and gains commitment;
  2. the ability to research complex issues, interpret regulations and regulatory rules/guidance,
  3. sound judgment in determining a recommendation or solution to a problem, ability to lead problem-solving discussions, ability and flexibility to adapt to shifting priorities; and
  4. to work independently as well as part of a team 

The applicant must be experienced and proficient with Word, Excel, PowerPoint, Outlook and related Microsoft Office software applications.

The successful candidate will possess

  1. strong organizational, coordination skills and interpersonal skills for facilitating Compliance risk assessments or compliance incident resolution;
  2. the ability to gather and analyze data and generate reports; and
  3. experience with hardware and software required in order to understand how these systems interface with the compliance regulations and statutes.

 The successful candidate must

  1. display excellent oral and written communication skills;
  2. the ability to communicate and make presentations to all levels of management and associates at all levels throughout the Company; and
  3. the ability to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. 

The successful candidate must

  1. be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence; and
  2. be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

 Preferred Skills: 

 Knowledge of organization and operations of the business areas being supported and experience in Claims, Enrollment and Billing, Sales, and/or Service. 

Prior experience in Medicare Advantage and Medicaid plan implementation and compliance operations.

 

Department

Department: Federal & State Government Programs

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.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Closing Date

Please apply before: 4.8.2021

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.

PHYSICAL DEMANDS:

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

Learn more about Business Operations