Sr. Utilization Management Compliance Analyst

Are you a champion for healthcare compliance and regulatory excellence? As a Sr. Utilization Management Compliance Analyst, you'll play a vital role in ensuring our Utilization Management (UM) program meets CMS and State requirements. Lead audit preparation, drive key compliance initiatives, and empower teams to uphold the highest standards in patient care.

Position is preferred in Central or Eastern Time Zones.

What You'll Do:

• Lead client and external audits for Utilization Management (UM) Operations, including managing all UM audits, corrective action activities, and reporting on findings and outcomes.

• Respond to UM Corrective Action Plans (CAPs) by identifying root causes, developing remediation plans, implementing compliance controls, and monitoring outcomes.

• Collaborate with the Liberty Compliance Department and cross-functional teams to review and update policies, procedures, and operational practices.

• Provide compliance training and guidance to staff on regulatory requirements and best practices.

• Research and resolve compliance issues related to CMS and State regulations, ensuring prompt and effective resolution.

• Report on UM performance metrics and compliance activities in Committee meetings, including UM Quality Committees.

• Work with Account Management, System Configuration, and other departments to review UM letter templates for regulatory, clinical, and operational accuracy.

• Prepare and assist in the submission of compliance reports to clients and the Compliance Department as needed.

• Monitor and stay informed of changes to CMS regulations and ensure timely implementation of updates within UM operations.

• Serve as a key support contact for compliance-related inquiries and issues within UM.

• Draft and review responses to CAPs and audit findings, ensuring clarity, accuracy, and timeliness.

• Support research and analysis of regulatory requirements, legislative changes, and organizational initiatives to assess their impact on UM operations.

• Take a lead role in developing, maintaining, and publishing internal and external policies and procedures.

• Communicate effectively with internal and external stakeholders to ensure alignment, manage expectations, and meet critical deadlines.

What You'll Bring: 

• Bachelor’s degree in Healthcare Administration, Public Health, Business Administration, or a related field; or an equivalent combination of education and relevant work experience.

• A minimum of 4 years of experience in utilization management or healthcare compliance, with a focus on CMS Medicaid and Medicare guidelines.

• Strong knowledge of CMS regulations, policies, and reporting requirements related to Medicare and Medicaid programs.

• Proficiency with Microsoft Office tools, including Outlook, Excel, Word, SharePoint, and PowerPoint.

• Excellent analytical skills and attention to detail, with the ability to interpret complex regulations and guidelines.

• Strong organizational and prioritization skills to manage multiple tasks and meet deadlines.

• Effective communication and interpersonal skills, with a collaborative mindset and the ability to work well in a team environment.

• Familiarity with compliance programs and auditing processes (preferred).

• Knowledge of HSP or Meditrac systems (preferred).