Senior Financial Compliance Analyst

Job Summary

Responsible for implementing and maintaining program standards and work plans for assigned financial compliance program. May assist leadership or lead in development of new program or standard work opportunities. Leads more complex compliance audits and investigations, ensuring complete resolution. Supports the management of compliance standards, laws, rules and regulations. Provides advice, guidance and recommendations to minimize risk.  Identifies root causes, trends/themes and assures plans and standards are in place including development, education and implementation of related procedures and policies.  Maintains expert knowledge in program focused area(s), including compliance policies, procedures, issues, and industry trends.  Handles the more complex level of investigations, inquiries, research and projects. Acts as a mentor to less experienced compliance team members.

Essential Functions

• Leads complex audits and investigations of compliance help line calls or other compliance contacts or reports, at the direction of management, and works with compliance leadership to determine the appropriate handling of such issues.  Performs necessary research - often using specialized expertise, documents findings, and follows up with applicable parties through complete resolution.  Collects, collates, and monitors audits data and activities to assure accuracy and to prevent, detect and correct non-compliance, illegal activities, and potential or actual fraud, waste or abuse.  Works with outside consultants or external regulatory agencies performing audits as necessary, under the direction of CCO, director, and/or manager. From time to time, performs investigations at the direction of legal counsel and works with legal counsel during such investigation to provide guidance, recommendations and other assistance as requested by legal counsel.  In such cases, the employee will report directly to legal counsel as opposed to employee’s up-line leadership, and such work with legal counsel shall be confidential and protected from disclosure by the attorney client privilege and work product protection.

• Prepares, enters, maintains, and reconciles data in the accounts payable system.  Assists in training new team members. Provides guidance and direction to less experienced Compliance professionals.

• Assists in the risk assessment and annual work plan activities.   Assumes accountability for the implementation of the work plans, ensuring achievement of measurable goals, objectives and corrective action plans for assigned program area.  Assists the manager and program lead in the development of standard work for auditing, investigations and corrective action and other departmental policies and procedures specific to assigned program area. Provides guidance to all compliance professionals and other key stakeholders on these processes. Uses risk-based methodologies, tools (CRA), and historical/current trends to assist in risk assessment processes.

• On a continuous basis, exercises administrative judgment and assumes responsibility for decisions, consequences and results having an impact on people, costs, and quality of service.  Assists with the development, implementation and maintenance of process improvement including departmental and/or organizational policies, procedures and methodologies - assuring compliance with laws and regulations while using accumulated data.  Reviews and monitors adherence to documented plans and programs including the Code of Excellence.

• Receives consultations and conducts analysis. Provides recommendation(s) to Compliance Officers and Relationship Management Teams.  Collaborates with Compliance Relationship Management Teams, operational and other areas in investigations (such as HR) and to implement ongoing risk identification and mitigation measures.  Proactively consults with Compliance Relationship Management Teams, operational areas and leadership through both formal (meetings, education) and informal means.  Plans, coordinates and executes effective monitoring and auditing plans to reduce non-compliance.

• Maintains knowledge of complex laws and regulations impacting healthcare and health insurance delivery and reimbursement.  Applies laws and regulations in daily situations while educating others through various means including formal training and annual compliance related education programs. Performs related assessments to assure compliance to laws, regulations and policies and procedures.

• Performs/leads/assists with more complex routine and for-cause financial compliance audits. Evaluates the accuracy of the regulatory standards, ICD/CPT/HCPCS and other party-payor requirements. Verifies adequacy of documentation in support of services billed, including medical necessity, and compliance with other documentation, co