Job Description
JOB DESCRIPTION SUMMARY
The primary responsibilities of the Compliance Analyst are to coordinate and perform risk-based participating dentists’ in-office and peer reviews, and support the organization’s other compliance activities.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Key Responsibilities
Fraud and Abuse
- Determines scopes of participating dentists’ reviews. Schedules reviews and collects pertinent documentations and information from the dentists and/or examining dentists.
- Analyzes and interprets data to determine participating dentists’ compliance with the contract documents and agreements.
- Prepares timely, detailed, and accurate workpapers, exhibits and reports.
- Determines and recommends findings and corrective actions. Communicates findings and corrective actions to participating dentists. Follows up with participating dentists to determine adequacy of corrective actions and to ensure timely resolution of each case.
- Analyzes effectiveness and efficiency of the in-office and peer reviews and proposes recommendations for enhancements.
- Raises awareness of fraud issues and serves as an expert for fraud and abuse matters.
Continuous/Daily Responsibilities
- Assists with Internal Monitoring, including preparing timely, detailed, and accurate workpapers and reports.
- Communicates findings to department managers and follows up to determine adequacy of corrective actions to ensure timely resolution.
- Develops and performs on-going compliance monitoring.
- Researches and monitors changes to laws and regulations.
- Manages HIPAA authorization forms and inputs authorization information into the internal system.
- Resolves compliance hotline and mailbox complaints and requests.
- Maintains complaints/concerns log.
- Investigates HIPAA potential breaches and recommends corrective actions, if needed.
- Plans, designs, and develops reports, including but not limited to ad hoc reports.
- Develops and maintains departmental policies and procedures.
- Obtains and maintains proficient knowledge of established policies, procedures, standards, practices, laws and regulations. This includes company, DDPA, state, federal and other mandates.
Other Duties and Responsibilities
- Assists the Compliance Manager with special projects.
- Coordinates and submits the annual DDPA surveys.
- Prioritizes and organizes own work to meet both formal and informal deadlines with minimal supervision.
- May be required to serve as back up on specific tasks to the Compliance Manager.
- Other miscellaneous duties and responsibilities as assigned by the Compliance Manager.
QUALIFICATIONS
Education
- College degree in business administration or health related field, or an equivalent combination of education, training, or work experience.
Licenses/Certification
- Certified Fraud Examiner (CFE) preferred.
Experience
- Three or more years of compliance, internal audit and/or fraud investigation experience.
- Dental claims processing experience is preferred.
Language Skills
Other Skills
- Active listening, learning, critical thinking, and time management
- Ability to exemplify social skills in a professional environment.
- Proficient in office applications (spreadsheets, presentations, word processing, and database management).
- Well-developed understanding of data analysis techniques and practices.
- Ability to analyze complex topics and issues and recommend solutions.
- Ability to communicate clearly and fluently in writing and orally with participating employees and management on sensitive matters.
- Ability to handle multiple tasks and adapt to changing priorities.
- Ability to handle confidential and sensitive issues and materials.
- Ability to work well under pressure and meet deadlines.
- Technical knowledge to understand computer applications for data analysis and problem-solving.
- Valid Hawaii driver’s license and personal transportation vehicle needed.
Physical & Visual Demands
- Ability to balance, stop, and crouch if/when necessary
- Ability to reach, push/pull, and lift items if/when necessary
- Ability to stand or walk for sustained periods of time
- Position may require repetitive motions and/or sedentary work
- Position requires close visual acuity to perform activities such as: preparing and analyzing data and figures, viewing a computer terminal, extensive reading, etc.
Mental Demands
- Duties require use of considerable initiative; analytical, good judgment, conflict management and computer skills; and working under minimum supervision.
- Requires dealing with difficult people and situations involving complex issues; establishing and maintaining cooperative and productive business and work relationships.
- Requires communicating effectively both orally and in writing; giving instructions or directives to others; and seeking information from a variety of sources.
EQUIPMENT USE
- Ability to use the following office equipment such as but not limited to: computers (laptops, tablets), scanner, calculator, photocopier, fax, and telephone.
WORKING CONDITIONS/ENVIRONMENT
- Hours of work: 8:00 AM - 4:30 PM, some extended hours required completing assignments.
- Monday through Friday, weekend and holiday work may be required.
- Requires working in enclosed air-conditioned office building.
- Must be able to travel by air and car.
