Compliance Analyst in Huntington Beach, California at Verda Healthcare Inc

Verda Healthcare, Inc. is a Medicare Advantage Prescriptions Drug Plan (MAPD) organization committed to the idea that healthcare should be easily and equitably accessed by all, currently available in Texas and Arizona. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a Compliance Analyst to join our growing company with many internal opportunities.

Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare is looking for people like you who value excellence, integrity, care and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.

Align your career goals with Verda Healthcare, Inc. and we will support you all the way.

Position Overview

The Compliance Analyst will support the Medicare Compliance Program and help ensure compliance with CMS and state regulatory requirements. This position conducts internal audits and monitoring, supports oversight of delegated entities and first tier, downstream, and related entities (FDRs), and supports the Special Investigations Unit (SIU) in fraud, waste, and abuse (FWA) prevention, detection, and investigation activities. The Compliance Analyst also supports the AVP, Compliance in day-to-day compliance program operations, including regulatory tracking, policies and procedures, training, committee support, and regulatory reporting.

This position reports to the AVP, Compliance.

Responsibilities

· Conduct internal audits and routine monitoring of operational areas, such as claims, utilization management, appeals and grievances, enrollment, Part D, and member communications, in accordance with the annual Compliance Audit and Monitoring Work Plan.

· Develop and maintain audit tools, sampling methodologies, workpapers, and audit reports; document findings clearly and communicate results to business owners and compliance leadership.

· Issue, track, and validate corrective action plans (CAPs) resulting from internal and delegated audits, and escalate overdue or ineffective remediation.

· Support readiness for CMS program audits, mock audits, and state regulatory reviews, including universe validation, document requests, and audit logistics.

· Support delegation oversight of delegated entities and first tier, downstream, and related entities (FDRs), including pre-delegation assessments, annual audits, ongoing monitoring, and performance scorecards.

· Review delegate reports and submissions (e.g., utilization management, claims, credentialing, and network reports) for timeliness, accuracy, and compliance with CMS requirements and contract terms; identify trends and escalate deficiencies.

· Maintain the delegated entity and FDR inventory, oversight calendar, and documentation of FDR compliance attestations, including training, exclusion screening, Code of Conduct, and offshore requirements.

· Prepare delegation oversight results and summaries for the Compliance Committee and other governance committees.

· Support the Special Investigations Unit (SIU) in the prevention, detection, and investigation of potential fraud, waste, and abuse (FWA), including intake and triage of referrals from the compliance hotline, internal departments, and data analytics.

· Assist with FWA investigations, including claims and medical record review, data analysis, records requests, and complete case documentation.

· Support FWA reporting, referrals to the Investigations Medicare Drug Integrity Contractor (I-MEDIC) and state agencies as appropriate, overpayment recovery tracking, and FWA program metrics.

· Perform and document monthly exclusion screening against the OIG LEIE, SAM, and CMS Preclusion List for employees, board members, providers, and FDRs.

· Support the AVP, Compliance in day-to-day compliance program operations, including maintaining compliance logs, trackers, and records for issues, inquiries, CAPs, and regulatory requests.

· Track and distribute CMS HPMS memos, regulatory updates, and state bulletins to impacted business owners, and follow up on implementation.

· Assist in the annual review and maintenance of compliance policies and procedures.

· Support compliance training and education, including annual General Compliance and FWA training and tracking of completion for employees and FDRs.

· Prepare agendas, minutes, materials, and reports for the Compliance Committee and Board of Directors.

· Assist with compliance hotline intake, compliance investigations, and regulatory reporting and responses to CMS and state regulators.

· Stay informed on Medicare Advantage and Part D regulatory changes and share relevant updates with the compliance team.

· This position requires daily in-office attendance to ensure effective collaboration and support of compliance activities.

· Other duties as assigned.

Professional Competencies

· Integrity and Discretion: Handles confidential information, including investigation and personnel matters, with professionalism and sound judgment.

· Attention to Detail: Produces accurate, well-supported audit workpapers, reports, and case files.

· Analytical Thinking: Reviews data and documentation to identify trends, root causes, and potential risk or FWA indicators.

· Objectivity: Applies professional skepticism and reports findings fairly and independently.

· Communication: Explains findings and requirements clearly, in writing and verbally, to business owners and delegated entities.

· Organization and Time Management: Manages multiple audits, investigations, and deadlines at the same time.

· Collaboration: Builds productive working relationships across departments and with delegated entities.

· Continuous Learning: Keeps current with changing CMS and state requirements.

Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!

Job Type: Full-time employment
Location: Huntington Beach, CA

Compensation Range: $72,384-85,000 annually

Actual compensation offered will be determined based on experience, qualifications, skills, internal equity (if available), and geographic location. This position may also be eligible for performance-based incentive compensation and benefits.

Benefits:

• 401(k)
• Paid time off (vacation, holiday, sick leave)
• Health insurance
• Dental Insurance
• Vision insurance
• Life insurance

Schedule:

• Full-time onsite (100% in-office)
• Hours of operations: 9am – 6pm
• Standard business hours Monday to Friday/weekends as needed
• Occasional travel may be required for meetings and training sessions.

Ability to commute/relocate:

• Reliably commute to the required office location, or planning to relocate before starting work.

PHYSICAL DEMANDS

Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.

*Other duties may be assigned in support of departmental goals.

· Bachelor’s degree in healthcare administration, business, public health, criminal justice, or a related field required. Equivalent work experience may be considered.

· At least 5 years of compliance, auditing, delegation oversight, or SIU/FWA experience within a health plan, managed care organization, or Medicare Advantage organization.

· Working knowledge of CMS Medicare Advantage and Part D requirements, including the Compliance Program Guidelines (Medicare Managed Care Manual Chapter 21 / Prescription Drug Benefit Manual Chapter 9).

· Experience conducting audits or monitoring, including sampling, workpapers, documenting findings, and tracking corrective action plans.

· Delegation oversight experience preferred, including FDR oversight and audits of delegated functions such as utilization management, claims, and credentialing.

· SIU or FWA experience preferred, including investigations, claims data review, and exclusion screening.

· Familiarity with CMS program audit protocols and universe requirements preferred.

· Certified in Healthcare Compliance (CHC), Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), or Certified Professional Coder (CPC) preferred.

· Proficiency in Microsoft Office, particularly Excel (pivot tables, lookups, and data analysis), as well as Word, PowerPoint, and SharePoint.

· Strong research, analytical, organizational, written communication, and verbal communication skills.

· Ability to work on-site daily at the company’s Huntington Beach, California office location.