Senior Analyst, Operational Regulatory Oversight- Medicare

Job Description

Job Summary

Establish a specifically designed Operational Regulatory Oversight program that effectively prevents and/or detects violation of applicable laws and regulations, which will protect the Business from liability and potential risk. Ensures that the Business understands and complies with applicable laws and regulations pertaining to the Health Care environment

Job Duties

The Operational/Regulatory Oversight Sr. Analyst works with health plans and operations departments to assess, oversee, and recommend business practices to ensure adherence to and compliance with State and Federal regulatory guidelines.  The Sr. Analyst develops and performs audits and oversight functions involving business-critical operations and vendor outsourcing arrangements for the company.  The  Sr. Analyst also validates the appropriate oversight, reporting, and controls are in place for the operational functions of the organization and outsourced vendor work. The Sr. Analyst providers peer level support to Analysts in the department through training and guidance on audits and corrective action plans.  The following are examples of specific duties of the role: 
• Interprets and analyzes state and federal regulatory rules, contracts, and other guidance to assess compliance and support building regulatory compliance audit procedures.  
• At the direction of management, coordinates and performs oversight audits and validation activities to ensure operational regulatory compliance with Federal and State laws and regulations, contract provisions, and internal policies and procedures.
• Supports the Operational Oversight Manager, Director, and team in the general development of the Operational Oversight Program including, but not limited to, analyzing risk areas, providing recommendations, performing audits, creating reports, educating and following up with business areas and owners to ensure processes and reporting exists to demonstrate compliance to regulatory requirements.  
• Supports Manager and Director with developing the Operational Oversight Work Plan, monitoring and reporting status of audit project tasks, and reporting on overall status of audit projects.
• Support health plans and MHI Business Owners with external regulatory audit requests by coordinating the audit from beginning to end, including  scheduling and facilitating meeting cadenances, the completion of audit risk assessments, the preparation and submission of sample universes, and submission of SOPs, training materials, and/or other evidence as part of regulatory audits. EX: DMHC, CMS active audits. Responsible for acting as the liaison between Operations and Compliance, in addition to providing business recommendations to identified risks and audit findings. 
• Based on regulatory and contractual requirements, and in collaboration with Business Owners, Corporate Compliance, and other key stakeholders, develops and communicates audit scope, objectives, and timelines; Leads development of audit procedures, job aids, work flows,  policy and procedures, and supporting materials for performance of audits. 
• Provides draft written reports of audits and findings to management, including recommendations for any identified finding; Supports management with presenting results and recommendations to Senior Leadership and department staff.
• Recommends new or updated job aids/, work flows, policy and procedures, reporting, controls, staffing needs, process, and/or technology changes based on audit results.
• Develops on-going oversight, data validation audits, Corrective Action Plans, and monitoring/tracking functions based on external regulatory audit results.
• Supports vendor outsources services oversight function; ensures appropriate vendor oversight procedures exist; verifies evidence of vendor performance to contract.
• Performs random audits with Internal Controls Department and Business Owners to validate and oversee established internal controls on a recurring schedule.
• Provides operational regulatory support for new lines of business and expansion efforts. With support from Management, review and identify new Key Performance Indicators (KPI) required, support updating master KPI repository playbook with regulatory citations identified. Identify and assist with creating new policy and procedures or modified existing documents.
• May develop and analyze trend reports to ensure contractual and regulatory compliance and performance improvement standards and for identification of any training needs; May create and maintain summary Key Performance Indicator (KPI) compliance reports for Corporate Operations.
• Demonstrates solid analytical and problem solving skills; self-starter.
• Ability to work independently or in a team, support multiple projects at once, and perform other duties or special projects as required.

• Must have experience working in  Medicare 
• Must have experience analyzing claims. 

Job Qualifications

REQUIRED EDUCATION:

Associate’s Degree and/or equivalent combination of education and Health Care related experience of 4+ years

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

4+ years experience in health care industry in related field

PREFERRED EDUCATION:

Bachelor’s degree in healthcare related field

PREFERRED EXPERIENCE:

4-6 years experience in healthcare industry in related field desired (Regulatory, Compliance and Auditing)

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

PMP Certification a plus

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $77,969 - $106,214 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.