Medicare Compliance Analyst

Job Summary

The Medicare Secondary Payer (MSP) Compliance Analyst supports the claims team by ensuring compliance with Section 111 of the MMSEA and other federal and state regulations. This role involves monitoring, analyzing, and interpreting MSP compliance requirements, implementing corrective actions, and ensuring alignment with regulatory standards.

Duties and Responsibilities

• Continuously exhibit and uphold Core Values of Integrity, Accountability, Communication and Teamwork, Innovation and Customer Service
• Stay abreast of CMS and other relevant regulatory bodies' guidelines, laws, and regulations to ensure compliance in all Medicare-related operations
• Serve as the primary liaison to MSP related vendors, ensuring effective communication and collaboration
• Analyze and revise company policies and procedures to ensure alignment with Medicare regulations and assist in drafting new policies as needed
• Perform regular risk assessments related to Medicare compliance, identifying areas for improvement and recommending corrective actions to minimize risks
• Participate in internal audits by reviewing the Claim System and external MSP Navigator data, and addressing audit findings and implementing corrective actions
• Develop and deliver training sessions for internal teams on MSP compliance topics, regulatory changes, and policy updates
• Prepare and submit accurate, timely reports to management and regulatory agencies, maintaining records of all compliance activities
• Monitor and analyze data to identify trends and potential compliance gaps, using insights to develop strategies to enhance compliance
• Work closely with departments such as Corporate Legal and Compliance to ensure adherence to all MSP-related compliance requirements
• Assist in investigating MSP compliance issues and collaborate with teams to develop and execute corrective action plans
• Manage and resolve complaints or issues related to MSP compliance, ensuring timely and effective solutions
• Keep detailed records of all compliance activities, including risk assessments, audits, training, and corrective actions
• Ensure adherence to state Medicaid requirements and monitor compliance with relevant regulations
• Ensure child support liens are managed in accordance with state regulation

Knowledge, Skills and Abilities

• Advanced knowledge of Medicare and MSP requirements, specifically related to 111 MMSEA (Medicare Reporting) standards
• Advanced knowledge of health insurance policies and procedures
• Advanced knowledge of CMS guidelines, Medicare Advantage, and Part D regulations, as well as state and federal healthcare laws
• Intermediate knowledge in the use of Verisk products, including MSP Navigator
• Intermediate knowledge of MSP Navigator and Guidewire products
• Advanced proficiency in regulatory reporting tools and systems
• Advanced proficiency in Microsoft Office Suite (Word, Excel, PowerPoint)
• Expertise in negotiating and resolving Medicare conditional payments (liens)
• Proficiency in managing liability and no-fault claims
• Skilled in establishing Medical Set Asides
• Ability to make critical and complex decisions using sound judgment
• Strategic thinker with creative problem-solving abilities
• Excellent written and verbal communication skills

Experience and Education

• High School degree required
• Bachelor's degree in related field (Healthcare Administration, Business) preferred
• Minimum of seven years of experience in Medicare compliance, regulatory and state filings, or a related field within the healthcare or insurance industry required
• MSP Accreditation preferred
• Experience with Medicare-related audits and compliance programs preferred

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