Who we are: :
Founded in 2016, we’ve become a trusted and valued partner for health plans and providers. We offer a modern integrated ecosystem of healthcare operations, processes, and products, with inherent scalability, efficiency, and predictable outcomes. Our BPaaS delivery solutions work behind the scenes to manage our customers’ complex admin operations, giving them elbow room to focus on their members’ needs and well-being.
Bending cost curves, guaranteeing outcomes, finding paths through roadblocks – that’s our way of life. Our customers count on us to safely navigate them through deadlocks. We have a strong global presence and a dedicated workforce of 4000+ people spread across the world.
Our brand is built on strong foundations of simplicity, honesty, and leadership, and we stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.
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:
- Bachelor's 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:
At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serves as a compass guiding every action and decision.
Guiding Principles
These principles illuminate the path of ‘how’ we operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.
Integrity
Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.
People-Centricity
Everything that we do reflects our deep bonds with peers and customers. These aren't mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.
Simplicity
Simplifying complexity underlines everything we do - this approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.
Leadership
Taking ownership is about taking initiative, being in-charge and driving things to completion. It’s a brave choice to ‘own’ all aspects of our work, ensuring we take full responsibility for everything we handle.
Mission
A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more – their members’ well-being.
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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