Senior Analyst, Operational Regulatory Oversight- ...

Job Description Job Summary Establish a specifically designed Operational Regulatory Oversight program that effectively prevents and/or detects violation of applicable laws and regulations, which will protect the Business from liability and potential risk. Ensures that the Business understands and complies with applicable laws and regulations pertaining to the Health Care environment Job Duties The Operational/Regulatory Oversight Sr. Analyst works with health plans and operations departments to assess, oversee, and recommend business practices to ensure adherence to and compliance with State and Federal regulatory guidelines. The Sr. Analyst develops and performs audits and oversight functions involving business-critical operations and vendor outsourcing arrangements for the company. The Sr. Analyst also validates the appropriate oversight, reporting, and controls are in place for the operational functions of the organization and outsourced vendor work. The Sr. Analyst providers peer level support to Analysts in the department through training and guidance on audits and corrective action plans. The following are examples of specific duties of the role: u2022 Interprets and analyzes state and federal regulatory rules, contracts, and other guidance to assess compliance and support building regulatory compliance audit procedures. u2022 At the direction of management, coordinates and performs oversight audits and validation activities to ensure operational regulatory compliance with Federal and State laws and regulations, contract provisions, and internal policies and procedures. u2022 Supports the Operational Oversight Manager, Director, and team in the general development of the Operational Oversight Program including, but not limited to, analyzing risk areas, providing recommendations, performing audits, creating reports, educating and following up with business areas and owners to ensure processes and reporting exists to demonstrate compliance to regulatory requirements. u2022 Supports Manager and Director with developing the Operational Oversight Work Plan, monitoring and reporting status of audit project tasks, and reporting on overall status of audit projects. u2022 Support health plans and MHI Business Owners with external regulatory audit requests by coordinating the audit from beginning to end, including scheduling and facilitating meeting cadenances, the completion of audit risk assessments, the preparation and submission of sample universes, and submission of SOPs, training materials, and/or other evidence as part of regulatory audits. EX: DMHC, CMS active audits. Responsible for acting as the liaison between Operations and Compliance, in addition to providing business recommendations to identified risks and audit findings. u2022 Based on regulatory and contractual requirements, and in collaboration with Business Owners, Corporate Compliance, and other key stakeholders, develops and communicates audit scope, objectives, and timelines; Leads development of audit procedures, job aids, work flows, policy and procedures, and supporting materials for performance of audits. u2022 Provides draft written reports of audits and findings to management, including recommendations for any identified finding; Supports management with presenting results and recommendations to Senior Leadership and department staff. u2022 Recommends new or updated job aids/, work flows, policy and procedures, reporting, controls, staffing needs, process, and/or technology changes based on audit results. u2022 Develops on-going oversight, data validation audits, Corrective Action Plans, and monitoring/tracking functions based on external regulatory audit results. u2022 Supports vendor outsources services oversight function; ensures appropriate vendor oversight procedures exist; verifies evidence of vendor performance to contract. u2022 Performs random audits with Internal Controls Department and Business Owners to validate and oversee established internal controls on a recurring schedule. u2022 Provides operational regulatory support for new lines of business and expansion efforts. With support from Management, review and identify new Key Performance Indicators (KPI) required, support updating master KPI repository playbook with regulatory citations identified. Identify and assist with creating new policy and procedures or modified existing documents. u2022 May develop and analyze trend reports to ensure contractual and regulatory compliance and performance improvement standards and for identification of any training needs; May create and maintain summary Key Performance Indicator (KPI) compliance reports for Corporate Operations. u2022 Demonstrates solid analytical and problem solving skills; self-starter. u2022 Ability to work independently or in a team, support multiple projects at once, and perform other duties or special projects as required. + Must have experience working in Medicare + Must have experience analyzing claims. Job Qualifications REQUIRED EDUCATION: Associateu2019s Degree and/or equivalent combination of education and Health Care related experience of 4+ years REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: 4+ years experience in health care industry in related field PREFERRED EDUCATION: Bacheloru2019s degree in healthcare related field PREFERRED EXPERIENCE: 4-6 years experience in healthcare industry in related field desired (Regulatory, Compliance and Auditing) PREFERRED LICENSE, CERTIFICATION, ASSOCIATION: PMP Certification a plus To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $77,969 - $80,000 / ANNUAL Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2025-09-10