Senior Analyst, Corporate Compliance

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Perform assigned healthcare compliance monitoring tasks.

• Utilize expertise in healthcare compliance, billing, coding, and risk adjustment for intricate or simultaneous reviews across various business sectors.

• Organize designated monitoring activities.

• Present findings and follow up on any identified concerns.

• Convey compliance risks and their impact on the business.

• Examine medical records, claims data, diagnosis codes, modifiers, and accompanying documentation.

• Assess the accuracy, completeness, and substantiation of HCC submissions, RAF impact, billed services, and coding results.

• Work collaboratively with Compliance, Legal, clinical operations, billing, coding, finance, and business teams.

• Lead meetings and relay information to management and stakeholders.

• Carry out and document monitoring tests.

• Analyze claims, encounters, billing, coding, and documentation data to discern trends, anomalies, control gaps, and compliance risks.

• Suggest practical solutions and pinpoint opportunities for automation and analytics.

⛳️ Requirements

• Over 2 years of experience in healthcare compliance, auditing, monitoring, billing, coding, claims review, medical record review, risk adjustment, investigations, or risk assessments within a healthcare organization, provider practice, health plan, or government healthcare program.

• In-depth understanding of CMS Medicare Part B and Part C regulations.

• Comprehensive knowledge of Medicare Advantage risk adjustment programs, HCC coding, RAF methodologies, provider documentation standards, medical record validation, coding compliance requirements, and documentation support standards.

• Proficient in reviewing medical records, claims data, diagnosis codes, modifiers, and supporting documentation.

• Strong analytical, deductive reasoning, problem-solving, and critical thinking abilities.

• Willingness to travel up to 5% (including by air).

• Capability to collaborate across Compliance, Legal, clinical operations, billing, coding, finance, and business teams.

• Proficient in facilitating meetings and conveying information clearly in both written and verbal formats.

• Consistent and reliable attendance is a vital aspect of the role.

• Ability to assess information, identify compliance vulnerabilities, address complex issues, and propose practical solutions.

• Capacity to uncover opportunities for utilizing automation and analytics to enhance monitoring efficiency.

• Strong skills in cross-functional communication and relationship-building.

• Competence in coordinating activities, executing and documenting monitoring tests, and communicating outcomes.

• Experience in analyzing claims, encounters, billing, coding, and documentation data.

• Strong business acumen, organizational and time management skills, along with meticulous attention to detail.

• Bachelor’s Degree; equivalent work experience may be accepted.

• High School Diploma/GED is mandatory.

• Certified Professional Coder (CPC) certification is required.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.