Establish a specifically designed Operational Regulatory Oversight program that effectively prevents and/or detects violation of applicable laws and regulations, which will protect the Business from liability and potential risk. Ensures that the Business understands and complies with applicable laws and regulations pertaining to the Health Care environment.
The Operational/Regulatory Oversight Analyst works with health plans and operations departments to assess, oversee, and recommend business practices to ensure adherence to and compliance with State and Federal regulatory guidelines. The Analyst develops and performs audits and oversight functions involving business-critical operations and vendor outsourcing arrangements for the company. The Analyst also validates the appropriate oversight, reporting, and controls are in place for the operational functions of the organization and outsourced vendor work. The following are examples of specific duties of the role:
Interprets and analyzes state and federal regulatory rules, contracts, and other guidance to assess compliance and support building regulatory compliance audit procedures.
At the direction of management, performs oversight audits and validation activities to ensure operational regulatory compliance with Federal and State laws and regulations, contract provisions, and internal policies and procedures.
Supports the Operational Oversight Manager, Director, and team in the general development of the Operational Oversight Program including, but not limited to, analyzing risk areas, performing audits, creating reports, educating and following up with business areas and owners to ensure processes and reporting exists to demonstrate compliance to regulatory requirements.
Supports Manager and Director with developing the Operational Oversight Work Plan, monitoring and reporting status of audit project tasks, and reporting on overall status of audit projects.
May support health plans and MHI Business Owners with external regulatory audit requests including the completion of audit risk assessments, the preparation and submission of sample universes, and submission of SOPs, training materials, and/or other evidence as part of regulatory audits. EX: DMHC, CMS active audits
Based on regulatory and contractual requirements, and in collaboration with Business Owners, Corporate Compliance, and other key stakeholders, develops and communicates audit scope, objectives, and timelines; Leads development of audit procedures, job aids, work flows, and supporting materials for performance of audits. Provides draft written reports of audits and findings to management; Supports management with presenting results and recommendations to Senior Leadership and department staff.
Recommends new or updated job aids/, work flows, reporting, controls, staffing needs, process, and/or technology changes based on audit results.
Develops on-going oversight, data validation audits, Corrective Action Plans, and monitoring/tracking functions based on external regulatory audit results.
Supports vendor outsources services oversight function; ensures appropriate vendor oversight procedures exist; verifies evidence of vendor performance to contract.
Coordinates with Internal Controls Department and Business Owners to validate and oversee established internal controls on a recurring schedule.
Provides operational regulatory support for new lines of business and expansion efforts.
May develop and analyze trend reports to ensure contractual and regulatory compliance and performance improvement standards and for identification of any training needs; May create and maintain summary Key Performance Indicator (KPI) compliance reports for Corporate Operations.
Demonstrates solid analytical and problem solving skills; self-starter.
Ability to work independently or in a team, support multiple projects at once, and perform other duties or special projects as required. Job Qualifications
Associate's Degree and/or equivalent combination of education and Health Care related experience of 3 years
2 years experience in health care industry in related field
Required License, Certification, Association
Bachelor's degree in healthcare related field
3-5 years experience in healthcare industry in related field desired (Regulatory, Compliance and Auditing)
Preferred License, Certification, Association
PMP Certification a plus
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.