Medical Compliance Analyst

Imperial Health is hiring a Compliance AnalystTo coordinate the compliance oversight activities for Imperial and with first tier, downstream and related entities (FDRs) as necessary to meet the contractual oversight regulatory requirements for the prevention, detection and correction of Fraud, Waste and Abuse (FWA) and Medicare program non-compliance as established by the Centers for Medicare and Medicaid Services (CMS)ESSENTIAL JOB *****Support the accurate and complete reporting of compliance activities to the compliance committees and external oversight entitiesReview and interpret all regulatory communications applicable to the organization and FDRs and ensure that appropriate action is taken, including dissemination to applicable areas and implementation of changes as needed Research and provide regulatory guidance and interpretation to inquiries through the use of applicable regulatory guidance including the Medicare Managed Care Manual, Medicare Prescription Drug Benefit Manual, and other regulatory guidancePerform and assess the effectiveness of regulatory compliance training and education activities applicable to Medicare Advantage and other regulatory requirementsCoordinate and perform ongoing internal monitoring of activities including tracking compliance and implementing appropriate action as requiredPerform audits of operational areas and FDRs (desk or off-site) in accordance with annual workplan or ad-hoc audits to determine compliance with CMS operational and Compliance Program requirements, including validation of data and internal controlsReview and submit comments, when necessary, for all assigned internal marketing reviews prior to their submission to CMS for approvalParticipate in CMS webinars, seminars, and conference calls applicable to assigned responsibilitiesResponsible for the issuance and management of compliance actions due to non-compliance resulting from reported issues, monitoring, and auditing activities.Coordinate the timely and accurate completion of CMS Part C and D Reporting Requirements and other required CMS submissions.Perform appropriate CMS data submission quality checks and update developed tools as necessaryMonitor, analyze, and communicate CMS Analyses and other reports related to complianceInvestigate and respond to reported issues and incidents of potential non-compliant or FWA activitiesCoordinate with internal departments and FDRs on issues related to compliance and FWACoordinate and assist the Compliance department in preparation activities for regulatory site visits and reviewsCoordinate with other members of the Compliance department or throughout the organization when assigned activities overlap or as directed by ManagementFor FDRs, perform pre-contract reviews, designation of prospective FDR contracts, and pre-assessments to ensure prospective entities have policies, operations, and staff to fulfill the proposed contracted activities of the planFor FDRs, communicate information regarding Imperial Health Plan's Compliance Program and monitor their adherence to requirementsResponsible for supporting the implementation of the seven elements of a compliance program and FDR oversight.

Created: 2025-05-15