Compliance Analyst

Job DescriptionJob DescriptionJOB SUMMARY & RESPONSIBILITIESThe Compliance Analyst is responsible for supporting the organization’s compliance program through monitoring, analysis, investigations, and risk identification activities. This role focuses on ensuring adherence to applicable laws, regulations, internal policies, and contractual requirements, while promoting a culture of integrity, accountability, and continuous improvement. The Compliance Analyst works cross-functionally to identify compliance risks, support mitigation strategies, and enhance the effectiveness of the Quality & Compliance Program.Responsibilities include, but are not limited to:Compliance Monitoring & OversightReview operational processes and related documentation and controls of pharmacy records and associated claims applying expertise in coding guidelines, medical policies, and payment procedures.Conduct desktop reviews, on-site audits and monitoring activities of the pharmacy network and third-party vendors to ensure the appropriateness of billing practices and compliance with regulatory requirements.Perform contract reviews to evaluate and ensure compliance with all applicable laws, regulations, and specific contractual obligations.Collaborate in the administration of the exclusion list screening process (e.g., OIG, GSA, and other regulatory bodies)Data Analysis & Risk IdentificationCollect, analyze, and interpret data to identify trends, anomalies, and potential compliance risksSupport the development of reports, dashboards, and metrics to monitor compliance performanceReview pharmacy records, claims, prescriptions, employee documentation, contracts, licenses, and other relevant billing-related information to identify potential risks, compliance gaps, and operational improvement opportunities.Investigations & Issue ResolutionConduct or support investigations related to compliance concerns, including Fraud, Waste, and Abuse (FWA), complaints, inquiries and Social Determinants of Health (SDOH) casesTriage and channel findings from investigations to the appropriate departments for resolution or interventionDocument findings and provide recommendations for corrective actionsRisk Mitigation & Continuous ImprovementAssist in the development and implementation of corrective action plans (CAPA)Monitor effectiveness of corrective actions and identify opportunities for process improvementIdentify and document the root cause that led to the identified error to design the corresponding action planRegulatory & Quality SupportSupport regulatory readiness and compliance with accreditation standards (e.g., URAC, ACHC, Joint Commission)Assist with audits, surveys, complaints management and regulatory requests (e.g., RFIs)Ensure adHerence to state and federal laws and regulations, internal policies, and contract requirements.Supports all functions related to Q&C Department internal/external reporting activities.Collects, prepares, reviews, and submits requested information, data, and documents to Executive Management Staff.Collaborate with the Q&C team, as needed to meet department goals, and perform other duties as assigned.Supports the Quality and Compliance Leadership in the administration of the Quality & Compliance Program and objectives.Actively supports Alivia Health Core Values and Mission through professional behavior and daily job performance.May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.Policies, Procedures & DocumentationSupport the development, review, and maintenance of compliance-related policies and proceduresEnsure proper documentation and recordkeeping of compliance activitiesCross-Functional CollaborationCollaborate with business units to address compliance risks and improve processesProvide guidance and support to operational teams on compliance-related mattersAnalyze and review confidential and highly sensitive investigative material/documents concerning insured, prescribers, or employees.Detect and correct potential errors that may result in potential recovery to the company.Give recommendations to the management team for possible solutions or improvement.Training & AwarenessSupport compliance training and education initiativesPromote awareness of compliance requirements and ethical standardsDevelop and deliver training programs and awareness material, serving as the primary resource for compliance education and ongoing staff development.ReportingPrepare and present compliance reports, findings, and recommendations to leadershipEscalate significant compliance risks or issues as appropriatePrepare and submit required fraud, waste, and abuse “FWA” reports to the management team, payors and/or regulatory agencies.Support in the regulatory agencies' request for information “RFI” received.Work with business units’ heads and staff to identify monitoring areas; collect, analyze, and interpret data and report results of monitoring initiatives.Experience:A minimum of three (3) years’ of experience in pharmacy field and performing audits in billing and coding, pharmacy records review, clinical information extraction, medical terminology, and risk identification in operational areas.Education, Certifications & Licenses:Bachelor’s degree in business administration, Healthcare Administration, Health Sciences, or related field required.Pharmacy Technician associate’s degree.Certifications / Licenses: Certification in billing and coding, such as Certified Coding Associate (CCA), or Certified Coding Specialist (CCS), or Certified Risk Adjustment Coder (CRC), or Certification in Medical Billing, or ICD-10-CM are preferred.Skills:Ethical leadership skills and able to lead by the values of the organization.Demonstrated emotional intelligence and diplomacy when engaging with others.Demonstrated advanced verbal and written communication skills.Ability to keep sensitive information confidential.Possess a facilitating mindset to build strong customer connectivity.Project management skills.Demonstrated problem solving skills.The ability to work independently and as part of a team.Ability to maintain objectivity and lack bias in evaluations.Critical thinking ability (analytical) with excellent organizational skills.Detail oriented.Technical Skills:Knowledge of Microsoft Office programs (Word, Excel, Power Point) is required.Basic knowledge in data analysis technique.Languages:Fully bilingual in English and Spanish (Written and Verbal) REQUIRED EDUCATION, TRAINING & LICENSURE/CERTIFICATIONSFor Pharmacy Technician it is required to have a license and registration.For other related health Since related field will depend on the specialty and requirements by applicable health boards.PHYSICAL REQUIREMENTSMust be able to remain in seated position for a large part of the workday.The person in this position needs to occasionally move about inside the office to access other employees, file cabinets, office machinery, etc.An employee must be able to talk, hear, and see, and must be able to grasp and reach objects.Visual acuity is necessary to read and write handwritten and typewritten materials and view a computer terminal.Constantly operates a computer and other office productivity machinery (i.e., a calculator, copy machine, and computer printer).

Use of hands (specifically fingers) is necessary for appropriate and efficient computer use.Must be able to lift a minimum ten (10) pounds.Valid driver’s license: safe driving record with the ability to drive during the day and nighttime.***EEOC F/M/V/D***