Senior Analyst, Corp Compliance

The Senior Analyst, Compliance COE will be a key member of the Compliance Monitoring team and will execute assigned compliance monitoring activities. This role applies healthcare compliance, billing, coding, and risk adjustment knowledge to execute assigned monitoring activities, which may include complex or concurrent reviews across multiple business areas. The role requires strong knowledge of Medicare Advantage, CMS risk adjustment programs, HCC coding, RAF methodologies, medical record validation, provider documentation standards, claims integrity, and coding compliance requirements. Additionally, this role coordinates assigned monitoring activities, including results reporting, issue follow-up, and communication of compliance risks and business impacts.

Responsibilities

Execute assigned compliance monitoring activities as a key member of the Compliance Monitoring team; Apply healthcare compliance, billing, coding, and risk adjustment knowledge to execute monitoring activities, which may include complex or concurrent reviews across multiple business areas; Coordinate assigned monitoring activities, including results reporting, issue follow-up, and communication of compliance risks and business impacts; Evaluate information, identify compliance risks, solve complex problems, and recommend practical solutions; Coordinate assigned activities, execute and document monitoring testing, and communicate results; Perform additional responsibilities as assigned by the supervisor or manager

Requirements

2+ years of experience in healthcare compliance, auditing, monitoring, billing, coding, claims review, medical record review, risk adjustment, investigations, or risk assessments within a healthcare organization, provider practice, health plan, or government healthcare program; Strong knowledge of CMS Medicare Part B and Part C requirements, Medicare Advantage risk adjustment programs, HCC coding, RAF methodologies, provider documentation standards, medical record validation, coding compliance requirements, and documentation support standards for billed services and submitted diagnosis codes; Experience reviewing medical records, claims data, diagnosis codes, modifiers, and supporting documentation to determine whether HCC submissions, RAF impact, billed services, and coding outcomes are accurate, complete, and supported; Strong analytical, deductive, problem solving, and critical thinking skills; Willingness to travel up to 5% (including by plane); Bachelors Degree or equivalent work experience; High School Diploma/GED; Certified Professional Coder (CPC)

Nice to have

Demonstrated ability to collaborate across Compliance, Legal, clinical operations, billing, coding, finance, and business teams to evaluate risk and support timely issue resolution; Ability to facilitate meetings and communicate information clearly in written and verbal form; Ability to identify opportunities to use automation and analytics to improve monitoring efficiency and provide actionable information to first-line business partners; Strong cross-functional communication and relationship-building skills in a matrixed organization; Experience analyzing claims, encounter, billing, coding, and documentation data to identify trends, outliers, control gaps, and compliance risk; Strong business acumen, organizational and time management skills, and attention to detail

Benefits

Medical, dental, and vision coverage; Paid time off; Retirement savings options; Wellness programs; Other resources based on eligibility; Eligibility for CVS Health bonus, commission or short-term incentive program