Description
Open to either Toledo (downtown) or Brooklyn, OH. - Hybrid, three days a week onsite either in Toledo or Brooklyn, OH.
Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
RAPS Compliance Analyst
Job Summary:
Under general supervision, implements and manages daily operations of Risk Adjustment compliance and related
activities for the Company's Medicare Advantage (Part C) and Qualified Health Plan (Commercial, ACA) health plan
programs. Ensures that regulatory requirements and operational policies and procedures are effectively implemented
and monitored and consistently interpreted across the department.
Responsibilities:
- Participates in the tracking and completion of required RADV audit procedures, including data collection and submission. Participates in mock auditing and ongoing monitoring of First Tier, Downstream and Related entities (FDRs), as well as department vendor oversight and monitoring.
- Triages vendor operational and compliance issues and questions received from all areas of the department and organization, understands the underlying intent of the questions, and researches and analyzes to provide responses and recommendations. Escalates compliance issues or concerns as necessary.
- Reviews and analyzes various materials for compliance with regulatory and operational guidelines and how they impact operational processes; coordinates or performs any required approvals and/or submission to regulatory bodies or others if required.
- Creates, tracks, and validates Incident Reports and Corrective Action Plans issued to internal business owners, as well as vendors.
- Prepares for audits (internal, external, mock, or regulatory) and due diligence activities. May include the collection, preparation, review, and submission of information, data, and documents to requestors, regulators, or auditors; accurate tracking; recordkeeping; rescheduling or coordinating facilities; and creating/delivering presentations.
- Attends all relevant industry trainings and presentations (REGTAP, HHS, AHIP, TARSC, CMS, etc.).
- Networks with and assists business owners and other staff regarding regulations specific to their operational responsibilities.
- Performs other duties as assigned.
Qualifications:
Education and Experience:
- Bachelors Degree in Business Administration, Healthcare Administration or related field.
- Equivalent education and experience directly related to the role may substitute for a degree.
- 3 years of experience in healthcare compliance, preferably including exposure to Medicare Advantage or Part D.
Professional Certification(s):
- Certified Compliance and Ethics Professional (CCEP) or certification in healthcare compliance a plus.
Technical Skills and Knowledge:
- Knowledge of statutory and federal regulations that affect health insurance products, specifically Medicare Advantage and Qualified Health Plan (ACA).
- Intermediate to advanced Microsoft Office skills; familiarity with LAN/WAN applications and SQL, QMF, and or other data extract methods.
- Understanding of operational, financial, and regulatory controls and risks and the ability to apply fundamental concepts to policies and processes.
- Knowledge of standard audit procedures and best practices.
Sr. RAPS Compliance Analyst
Job Summary:
Ensures compliance with regulations and requirements related to Medicare Advantage (MA) and ACA/Commercial Risk Adjustment Data Validation Audits (RADVs). Performs periodic mock audits including review of data extraction procedures and data analysis. Documents findings and recommendations to determine organizational compliance with ACA/MA RADV audit requirements. Determines whether policies and procedures related to risk adjustment are effective, efficient, and in compliance with Centers for Medicare and Medicaid Services (CMS) regulatory guidelines.
Responsibilities:
- Collects, analyzes, interprets and documents information as part of preparing reports, including activities associated with preparation for any audits including those by independent third parties, Health and Human Services (HHS) or CMS.
- Creates and manages oversight of policies and procedures to ensure regulatory compliance is being met.
- Maintains knowledge of regulatory guideline changes and how they impact operational processes. Monitors developments and changes transmitted through Regtap for ACA/RADV and the Health Plan Management System (HPMS) that impact data validation requirements and brings to the attention of management.
- Manages the development, tracking and completion of required RADV audit protocols and required data collection and submission for filings, including first tier/downstream and related entities (FDR) roles in data collection. Leads mock audits; develops and implements quality assurance into risk adjustment programs. Leads annual RADVs. Reviews and monitors FDR role in producing data for audits.
- Ensures consistent interpretation of regulatory guidance across multiple departments and compilation of data for audits.
- Manages issuance and coordination of internal and vendor incident and corrective action plan management for risk adjustment operations, including validation audit of all remediation action plans.
- Networks with and assists business owners and other staff regarding regulations specific to their data collection and submission work. Works closely with internal business and IT areas and manages activities with third party IVA/IVC as regulations require.
- Prepares work papers and exemplars as needed or required by HHS/CMS and independent third parties
- Responds to requests for information about the compliance program from outside regulatory entities. Responds to requests for RADV audits from HHS/CMS and independent third parties.
- Performs other duties as assigned
Qualifications:
Education and Experience:
- Bachelors Degree in Business Administration, Healthcare Administration or related field.
- 5 years progressive experience with healthcare compliance which includes 3 years in Risk Adjustment Data Validation (RADV) data collection or data analytic activities.
Professional Certification(s):
- Certified in Healthcare Compliance preferred.
Technical Skills and Knowledge:
- Comprehensive knowledge of RADV requirements for Medicare Advantage and ACA Plans and the ability to apply concepts to operations.
- Knowledge of health insurance operations compliance risk areas and best practices.
- Knowledge of CMS audit procedures.
- Advanced Microsoft Office skills; familiarity with LAN/WAN applications
- Strong project management skills
#LI-MM1
Apply on company website
Find Connections via Linkedin
