This key position helps to design, direct and execute all aspects of SIHO Insurance Services’ (SIHO, or the Company) compliance program, whether related to SIHO’s commercial business, its Medicare Advantage (MA) contract with the Centers for Medicare and Medicaid Services (CMS) or its ACO activities.
The Compliance Analyst’s role is to work collaboratively throughout the Company to ensure and document the Company’s compliance with all applicable laws, rules, regulations, manuals and transmittals pertaining to its business activities. The Compliance Analyst will also be responsible for HMO, TPA, and other licensing applications and maintenance, and for organization, maintenance and review of Policies and Procedures.
The Compliance Analyst will be a high-profile position within the Company, reporting directly to the Company’s Chief Compliance Officer. The Compliance Analyst may have matrixed reporting relationships with the Company’s officers, boards and committees.
Duties and Responsibilities:
- Helps to develop, implement, monitor and document all aspects of the Company’s comprehensive Compliance Program, including program structure, educational requirements, reporting, complaint mechanisms, response and correction procedures, and compliance expectations for all personnel and vendors.
- Develops, implements and documents methods and programs for reporting and responding to instances of noncompliance and potential fraud, waste, or abuse. Must maintain documentation for each report of potential noncompliance or potential fraud, waste, or abuse.
- Interfaces as needed with CMS, state regulators and other third parties regarding compliance matters.
- Researches and prepares responses to CMS or other compliance inquiries or investigations; produces and implements corrective action plans as appropriate.
- Is aware of daily business activity of Company’s internal departments and external vendors and coordinates with and communicates to internal departments and external vendors, where appropriate, regarding all compliance activities and programs.
- Develops and presents training programs for the Company’s employees, vendors and other personnel to ensure they are knowledgeable about the compliance program, Company Code of Conduct, compliance policies and procedures, and applicable statutory and regulatory requirements.
- Takes the lead or assists, as appropriate in the circumstances, in the development of, and updates to, the Company’s written compliance plans and the policies and procedures generally related to or impacting compliance.
- Receives, reviews and disseminates for Company adoption CMS transmittals and HPMS notices.
- As needed, uploading of Medicare applications, bid submissions, submissions of sales events and Parts C and D reporting data in HPMS.
- Reviews and corrects, as necessary, materials to be submitted to CMS or used by the Company for marketing, code management, or other purposes.
- Ensures compliance with program requirements and regulations governing service area expansions, Plan Benefit Packages, and HPMS information.
- Works collaboratively with internal and external personnel to gain efficiencies and eliminate compliance gaps.
- Documents compliance procedures, findings and reports.
- Participates in, and manages as necessary, internal and external audits involving compliance matters.
- Reviews, investigates and documents from a compliance perspective the performance of delegated entities, first tier, downstream entities and independent contractors who furnish services to the Company, including with respect to all standards of business conduct, privacy and fraud, waste and abuse.
- Ensures that the DHHS OIG and Government Services Administration exclusion lists have been checked with respect to all employees, governing body members, and FDRs monthly and coordinates any resulting personnel issues with Human Resources, Security, Legal or other departments as appropriate.
- Assists in developing and implements the Company’s production, retention and maintenance of Policies and Procedures.
- Prepares, files, renews and maintains the Company’s HMO, TPA, and other licenses necessary or appropriate to conduct its business.
- Manages and maintains business critical corporate documents, such as licenses, contracts, leases, and others key documents.