Responsible for carrying out compliance reviews that provide reasonable assurance company personnel and/or applicable third-party vendors are complying with current corporate policies and all laws and regulations. Collects and prepares information to provide support to Divisional Management. Provides management with recommendations to better manage risks, strengthen internal controls and deter and reduce non-compliance. Reviews compliance procedures and reports on findings to management. Assists Management in coordination of external agencies regulatory and compliance audits that may include DOI Exams, CMS Audits, BCBSA Audits, applicable Third Party Delegated Entities (DDE) audits, and/or scheduled special reviews as assigned. Accountable for complying with all laws and regulations associated with duties and responsibilities.

• This role does not manage people
• This job reports to: Departmental Leadership
• Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with: Internal - All levels of company management and personnel. Moderate involvement and exposure to senior management team. External - Consultants, auditors, investigators, regulatory bodies, BCBS Association, and other external sources that may provide information for a review such as providers and other Blue Cross plans.

• Bachelor's in Business Administration, Health Administration or a related field as deemed necessary by department management required
• Master's in related field preferred
• Four years of related experience can be used in lieu of a Bachelor’s degree.

• Must have a minimum of 4 years of experience in a predominantly audit and analytical position related to compliance or audit. Compliance Audit experience is preferred.
• Previous experience in commercial or government compliance programs such as Medicare Advantage, Medicaid, Commercial, or Health Care Reform is required.
• Preferred experience for Medicare Compliance: Medicare plans and services, Medicare related regulatory requirements
• Preferred experience for Commercial Compliance: Privacy and ethics, Business code of conduct and compliance, Fraud investigation practices
• Preferred experience for Information Governance Office: Privacy regulations and standards, Information governance / records management practices, Incident response / internal investigation experience
• Preferred experience for Vendor Compliance: Third Party/vendor contract terms, compliance, and controls requirements related to delegated services, Working knowledge of accreditation standards and requirements for URAC and /or NCQA, General audit standards, processes and practices, Prior clinical environment experience and/or strong working knowledge of clinical practices

• Position requires strong human relation skills in addition to analytical ability. Also, strong communication skills both written and oral.
• Ability to manage time and personnel on a project and everyday basis.
• Working knowledge of relevant software is required.
• Incumbent must maintain complete confidentiality of information encountered.
• Ability to work extended hours with some travel required.

• An advanced healthcare related industry certification such as CIA, CPA, CHC preferred

• With minimal supervision by department management, independently conducts basic to complex audits, reviews, periodic evaluations and special reviews as identified in annual risk assessment or as specified by management, to determine company’s compliance with laws and regulations.
• Actively researches and remains current with applicable State and Federal laws and regulations and may include standard operating procedures relevant to the Code of Business Conduct and Compliance program, to determine the company’s state of compliance.
• Advises applicable management of changes and new regulations and helps ensure that their assigned area is tracking all applicable State and Federal laws and regulations in applicable databases.
• With minimal supervision, conducts special reviews, which may include ethics investigations originating as a result of alleged violations of the Code of Conduct (including fraud, abuses, and other related improprieties) and reports findings to applicable management.
• Advises various levels of personnel on compliance issues related to organization products and services, third party delegated products and services, and applicable regulations and laws, where applicable, to ensure the company is in compliance. Serves as a Compliance subject matter expert to other areas of the company as needed.
• As assigned by department management, completes assigned portions of the department’s risk assessment and helps guide the overall risk assessment effort.
• Assists department management in other areas, as assigned to include training and education of the Company employees regarding audience applicable Compliance program(s) and other compliance related education to ensure employee understanding of compliance and where applicable ethics.
• When requested, and under minimal supervision of department management, leads, coordinates and/or assists with external audits, special projects and examinations to ensure their successful completion.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.