The Compliance Analyst assesses organizational exposure to regulatory, operational, and financial risk by evaluating compliance with federal and state requirements, internal policies, and industry standards. The role supports enterprise risk mitigation efforts, conducts compliance investigations, analyzes trends to identify emerging risks, and collaborates with clinical, administrative, and operational leaders to strengthen controls and promote a culture of compliance across the medical network.
Essential Functions:Regulatory Monitoring and Interpretation:- Monitor regulatory developments affecting professional services and interpret changes across CMS, OIG, AMA CPT, and commercial payer requirements to identify organizational risk exposure.
- Evaluate operational impact of new or revised regulations on clinical, administrative, and documentation workflows, highlighting areas of compliance vulnerability and recommending risk'mitigation strategies.
- Develop and disseminate compliance guidance by translating regulatory updates into clear, actionable alerts and decision support tools for stakeholders across the medical network.
- Identify trends in errors, denials, and potential compliance risks.
Investigations and Risk Mitigation:- Conduct compliance investigations into billing irregularities, payer inquiries, and suspected fraud, waste, or abuse to assess organizational risk and determine root causes.
- Partner with legal and compliance leaders to design and implement corrective action plans that strengthen internal controls and reduce regulatory exposure.
- Support audit response activities by coordinating documentation, preparing formal submissions, and assisting with appeals to ensure accurate and defensible representation of organizational practices.
Data Analysis and Reporting:- Analyze operational and compliance data to identify trends, anomalies, and risk indicators across coding, billing, and documentation processes.
- Develop risk'focused reporting including dashboards, audit summaries, and compliance performance metrics to inform leadership decision'making.
- Monitor key compliance indicators such as denial patterns, coding accuracy, audit outcomes, and other risk signals to proactively identify emerging vulnerabilities.
Compliance Program Support:- Develop and deliver training on professional fee compliance, COI, Stark, AKS, and general compliance expectations.
- Maintain documentation of audits, investigations, and corrective actions in accordance with compliance program standards.
- Support risk assessments, internal reviews, and external audits by providing data, analysis, and subject'matter expertise.
- Contribute to policy development and updates related to billing, physician arrangements, and organizational compliance.
- Partner with coders, providers, practice managers, and revenue cycle teams to resolve compliance issues.
- Support development of policies and procedures related to coding, billing, and documentation compliance.
Minimum Requirements:- High School Diploma or equivalent. Bachelor's degree in Business, Healthcare Administration, or similar field preferred.
- CHC, CHPC, CPC, or COC certification or the ability to obtain certification within 6-9 months of hire
Experience:- Experience in conducting investigations related to potential fraud, waste, or abuse and operational risk within a physician practice or health system.
- Strong analytical skills with the ability to interpret clinical documentation and billing data.
- Excellent communication skills, especially in explaining complex regulatory concepts.
Other Knowledge, Skills, and Abilities:- Strong documentation and reporting skills for preparing dashboards, audit summaries, and investigation findings.
- Proficiency in data analysis using Excel, BI tools, or audit software to identify trends, anomalies, and risk indicators.
- Ability to interpret complex regulations and translate them into operational guidance.
- Experience developing compliance education or training materials.
