Compliance Analyst PACE Program - Oceanside, United States - Neighborhood Healthcare

Description

Community health is about more than just vaccines and checkups. It's about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We're with you every step of the way, with the care you need for each of life's chapters. At Neighborhood, we are Better Together.

As a private, non-profit 501(C) (3) community health organization, we serve over 350k medical, dental, and behavioral health visits from more than 90k people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.

We have been doing this since 1969 and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you join the team

ROLE OVERVIEW and PURPOSE

The Compliance Analyst plays a pivotal role in upholding regulatory standards and ensuring compliance within the Program of All-Inclusive Care for the Elderly (PACE). This multifaceted role involves meticulous tracking of various logs, proactive involvement, and collaboration with the Quality Department in grievances and complaints processing, comprehensive data collection and analysis, and active participation in maintaining organizational standards. Additionally, this role will engage in frequent communication and presentations to stakeholders by facilitating compliance communication and awareness across different levels of the organization.

RESPONSIBILITIES

• Collaborates with the PACE Compliance Officer and Compliance Committee to conduct rigorous risk assessments, which are tailored to the unique needs and operational intricacies of the PACE program
• Works with PACE Compliance Officer to evaluate operational areas and processes within the PACE program by identifying potential compliance risks specific to elder care and healthcare services for the elderly population
• Provides comprehensive support for both internal and external audit processes by focusing on compliance with PACE program regulations, contractual agreements, and organizational policies
• Monitors key metrics using advanced dashboard tools designed for tracking PACE program performance, ensuring alignment with regulatory requirements, and best practices in elder care
• Gathers, organizes, and enters data tailored to the unique data requirements of the PACE program compliance reporting purposes, including participant demographics, healthcare utilization, and outcomes
• Conducts thorough analysis of collected data independently to identify emerging trends, areas for improvement, and potential risks specific to the provision of comprehensive care services within the PACE program framework
• Provides support for compliance initiatives and addressing specific regulatory/quality assurance needs of the PACE program
• Works with PACE Compliance Officer implementation, and refinement of compliance-related policies, procedures, and training programs tailored to support the delivery of high-quality care within the PACE program
• Analyzes claims data for potential instances of billing fraud by PACE providers, such as upcoding or unbundling of services
• Maintains the Compliance and Ethics Hotline, responds to reports of potential fraud, waste, and abuse (FWA), initiates necessary investigations, and ensures timely resolutions
• Prepares and delivers presentations to communicate compliance policies, updates, and procedures to stakeholders, including PACE participants, providers, and internal staff
• Facilitates communication with vendors and the Interdisciplinary Team (IDT) to address compliance issues identified during audits or investigations and ensures prompt resolutions
• Aids in logging allegations of suspected FWA into the Fraud Tracking Database and conducting thorough investigations into reported incidents
• Reviews documentation related to allegations of non-compliance with PACE program requirements and conduct interviews with relevant parties to gather evidence, reporting findings to the PACE Compliance Officer
• Conducts audits of PACE program documentation to assess compliance with CMS requirements and identifies areas for improvements
• Contributes insights and feedback on the performance of the compliance program based on their observations
• Assists in facilitating the referral of confirmed instances of FWA to appropriate regulatory agencies, such as the OIG or state Medicaid Fraud Control Units
• Ensures timely reporting of potential FWA cases to CMS and other oversight agencies independently in accordance with regulatory requirements
• Collaborates with the Quality Assurance Specialist to investigate participant grievances related to compliance issues, such as denial of services or improper billing
• Ensures compliance with CMS requirements for documenting and resolving participant grievances and maintaining detailed records of investigations and outcomes
• Reviews contracts with contracted PACE providers independently to ensure compliance with regulatory requirements and program standards
• Assists in conducting audits of delegated activities to verify compliance with contractual obligations and regulatory standards, such as home health services or transportation
• Works with the PACE Compliance Officer to review the exclusion and preclusion screening data submitted to ensure compliance with federal healthcare program requirements
• Analyzes the screening results to identify any instances where providers may be listed on the exclusion or preclusion lists
• Collaborates with the PACE Compliance Officer to take appropriate action, such as notifying regulatory agencies, reporting findings, and recommending the termination of contracts with affected providers, if necessary
• Assists in developing corrective action plans to address compliance issues identified during audits or investigations under the guidance of the PACE Compliance Officer, including ensuring timely implementation and monitoring of progress
• Reports violations of program requirements to appropriate enforcement agencies and takes corrective action to prevent recurrence, including reporting actions taken
• Conducts training sessions for PACE staff on identifying potential instances of FWA, such as improper billing practices or kickbacks, under the supervision of the PACE Compliance Officer
• Participates in workshops and webinars on emerging trends in healthcare fraud schemes independently and share knowledge with PACE staff to enhance awareness and vigilance

EDUCATION/EXPERIENCE

• Associate's degree in healthcare administration, business administration, public health, or related discipline required
• Four years' healthcare compliance required; healthcare compliance experience within California preferred
• Experience conducting risk assessments, audits, and data analysis to ensure compliance with healthcare regulations and organizational policies preferred
• Experience working in PACE programs is preferred

ADDITIONAL QUALIFICATIONS (Knowledge, Skills and Abilities)

• Excellent verbal and written communication skills, including superior composition, typing and proofreading skills
• Ability to spreadsheet software for data analysis and reporting, such as Excel
• Ability to interpret a variety of instructions in written, oral, diagram, or schedule form
• Knowledgeable about and experience with regulatory requirements governing healthcare programs in California, including Medicare and Medicaid regulations
• Knowledgeable about and experience with risk assessment methodologies and auditing processes, ensuring meticulous attention to detail and accuracy
• Ability to demonstrate a proactive approach to compliance management by overseeing and monitoring delegated activities
• Ability to conduct thorough investigations and gather evidence meticulously, displaying strong analytical and problem-solving skills
• Ability to promote a culture of compliance within the organization
• Ability to successfully manage multiple tasks simultaneously
• Excellent planning and organizational ability
• Ability to work as part of a team as well as independently
• Ability to work with highly confidential information in a professional and ethical manner

Physical Requirements

• Ability to lift/carry 10 lbs/weight
• Ability to stand for long periods of time

Neighborhood Healthcare offers a generous benefit plan that includes:Partially company paid Medical, Dental, and Vision Plans. Two plus weeks of vacation, Nine Holidays including two Floating Holidays of your choosing, Sick/Personal time, Volunteer Time Off (VTO), 403b Retirement plan (similar to a 401k), optional Health and Wellness events, and much more

Pay range: $$65,400-$86,800 annually, depending on experience (exempt position)