Compliance Operations Analyst

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Take ownership of designated SOC audit tasks, which involves coordinating audit requests, gathering evidence, reviewing documentation, monitoring progress, and following up with internal business stakeholders.

• Assist with audits pertaining to claims accuracy, validation of pass-through pricing, accumulator and benefit configuration, claims adjudication, and operational compliance.

• Conduct claims sampling, testing, and validation by employing established audit methodologies and procedures.

• Analyze claims data, system outputs, SOC control evidence, and operational records to uncover discrepancies, trends, and control deficiencies.

• Prepare and maintain audit work papers, testing outcomes, evidence files, SOC documentation, and supporting materials.

• Monitor audit requests, unresolved items, remediation requirements, and management responses.

• Aid in regulatory and contractual compliance testing, which includes HIPAA/HITECH, ERISA, and state PBM transparency mandates.

• Support delegated vendor audits, third-party oversight evaluations, service-level agreement validations, and monitoring for fraud, waste, and abuse.

• Compose audit summaries, issue logs, testing results, finding narratives, dashboards, and status reports.

• Maintain remediation trackers and verify the completion of corrective actions through documentation review and follow-up testing.

• Assist with SOP, governance, process documentation, audit inventory, and compliance monitoring efforts.

• Analyze claims and operational data to pinpoint trends, anomalies, compliance risks, and avenues for process enhancement.

• Adhere to HIPAA responsibilities and safeguard PHI, PII, claims data, client information, and internal business records.

• Carry out other assigned duties as necessary.

⛳️ Requirements

• Practical knowledge of PBM operations, claims adjudication, benefit design, pricing, network, clinical programs, or healthcare operations.

• Familiarity with compliance, audit, quality assurance, risk assessment, or internal control principles.

• Excellent analytical abilities for reviewing claims data, recognizing trends, and summarizing findings.

• Strong attention to detail and precise documentation of testing outcomes, evidence, and audit conclusions.

• Capability to adhere to procedures, manage deadlines, and support multiple projects or audits concurrently.

• Clear written and verbal communication skills.

• High integrity, discretion with PHI/PII, and sound judgment in managing confidential information.

• Proficiency in Microsoft Office applications, including Excel, Word, Outlook, SharePoint, and Teams.

• Availability to work during core hours of 8:00 AM to 5:00 PM CT and adjust work hours for meetings across time zones.

• Willingness to work extended hours, weekends, and holidays based on industry needs.

• Full-time/exempt availability.

🏝️ Benefits

• Medical, Dental and Vision Insurance.

• Disability and Life Insurance.

• Employee Assistance Program.

• Options for remote work.

• Generous Paid-Time Off.

• Annual Reviews and Development Plans.

• Retirement Plan with company match, fully vested immediately.