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Compliance and Resolution Analyst The candidate will analyze, research and develop policies, procedures and related documentation responsive to regulatory and contractual requirements. Analyze, research and develop reporting on member and provider appeals, grievances, and aspects of health plan coverage consistent with contract, regulatory and/or accreditation requirements. Analyzes, researches and develops all appeals and grievance reporting including department inventory, trending, regulatory requirements, audits, employer group and internal department scheduled and ad hoc requests. Understands inventory tracking system application to develop new, more efficient use of the system to meet reporting requirements, and to recommend and implement changes/updates and provide remedial user training to ensure compliance. Identifies required changes to policies and procedures based on case resolutions, statutory or regulatory changes, or accreditation requirements. Proposes changes to management based on identification and analysis. Analyzes and identifies issues that require multiple department efforts to resolve, then coordinates discussions and meetings to develop process to resolve those issues. Presents recommendations to internal committees and executive management, and assist with the implementation of resulting decisions for change/resolution. Assists supervisor/manager in responding to internal investigations, reviews, and audits; regulatory inquiries; and accreditation related audits. Evaluates/monitors work performance of staff and reports progress, barriers, and solutions to Supervisor. Collaborates with other departments to improve processes and workflows across departments. Facilitates cross-departmental discussions and actions to promote effectiveness and efficiencies. Takes a proactive role in digesting and communicating any new regulation, standard, business change, etc. affecting the member advocacy and/or appeals process. Assists in the coordination of changes among departments. Assists in determining internal and external impacts. Finalizes presentations of internal and external appeals reviews, including performing quality assurance of case documents. Conducts presentation for internal committees and groups relating to processes and reports. Assists in special projects, analyzes and documents trends for supervisor's review, and performs other duties as assigned. Must have Bachelor's degree in communications, statistics, logic, English, business administration, or related field, or equivalent combination of education and experience. Should have 3+ years of experience as an analyst, investigator, researcher, paralegal or closely related occupations which demonstrate knowledge of administrative procedures involved in analytical functions and/or assessing and assuring compliance. Organizational skills for tracking multiple projects and priorities is required. Demonstrated experience in handling complex situations requiring problem identification and resolution is needed. 3+ years experience in using Microsoft Office applications including Word, Excel and Outlook is must. Working knowledge of Microsoft Office applications including Word, Excel and PowerPoint is essential. Note: This is a 1 year contract role.
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