South Country Health Alliance has an immediate need for a Compliance and Program Integrity Analyst

The Compliance and Program Integrity Analyst will participate in the implementation of many aspects of the Compliance Program. This includes monitoring the organization's compliance with applicable state and federal rules and regulations, ensuring the integrity of data is maintained, data analytics, investigations, management of policies and documentation systems, and responding to questions and concerns.

Required: Required: Bachelor's degree with at least two (2) years of experience in healthcare compliance, program integrity, investigations, or fraud detection; 5+ years of experience in lieu of degree.

Preferred: Experience analyzing healthcare claims data or supporting fraud, waste, and abuse investigations preferred.

Skill Sets: Excellent organization skills with high level focus on data accuracy and reporting; strong analytical and problem-solving skills; effective communication and presentation skills; excellent research skills, primarily with state/federal statutes and other regulations; high degree of integrity and ability to exercise independent judgment; experience working in SharePoint; advanced Microsoft Excel skills; and proficient in other Microsoft Office applications.

South Country Health Alliance offers a full range of comprehensive benefits and competitive pay.

Must be legally authorized to work in the U.S. (No sponsorship available)

Compliance and Program Integrity Analyst

Department: Compliance

Reports To: Compliance and Government Relations Manager

Pay Grade: 8 - Exempt

Supervises: None

Approved By: Compliance Officer

Revision Date: August 11, 2026

JOB PURPOSE or JOB SUMMARY:

The Compliance and Program Integrity Analyst will participate in the implementation of many aspects of the Compliance Program. This includes monitoring the organization's compliance with applicable state and federal rules and regulations, ensuring the integrity of data is maintained, data analytics, investigations, management of policies and documentation systems, and responding to questions and concerns.

QUALIFICATIONS:

Required: Required: Bachelor's degree with at least two (2) years of experience in healthcare compliance, program integrity, investigations, or fraud detection; 5+ years of experience in lieu of degree.

Preferred: Experience analyzing healthcare claims data or supporting fraud, waste, and abuse investigations.

Skill Sets: Excellent organization skills with high level focus on data accuracy and reporting; strong analytical and problem-solving skills; effective communication and presentation skills; excellent research skills, primarily with state/federal statutes and other regulations; high degree of integrity and ability to exercise independent judgment; experience working in SharePoint; advanced Microsoft Excel skills; and proficient in other Microsoft Office applications.

ESSENTIAL DUTIES and RESPONSIBILITIES:

The duties and responsibilities listed below reflect the general details necessary to describe the essential functions of the position and shall not be construed as the only duties that may be assigned for the position.

1. Monitor the organization's compliance program with applicable state and federal rules and regulations. Maintain a current working knowledge of federal and state regulations and policies as they affect South Country through routine review of applicable published government publications, regulatory guidance, industry resources, and other relevant materials.

2. Analyze claim data and utilize fraud detection platforms to identify aberrant billing patterns, trends, and potential indicators of fraud or abuse, and recommend providers for further review and investigation.

3. Participate in a team-oriented environment to assist in the investigation of potential fraud and abuse cases. Review of claims data, medical records, and other system information necessary to complete an investigation.

4. Document, track, and report fraud and abuse investigations and HIPAA related issues as they arise. Follow up and document all investigations and cases in Compliance Department's electronic documentation system.

5. Actively support and coordinate the management of day-to-day compliance program operations to effectively incorporate a culture of compliance into the health plan. Must be effective in fostering relationships and team-building throughout the organization.

6. Work to enhance South Country's compliance programs, including education programs addressing compliance. May assist in educating/training staff of compliance-related issues or concerns affecting the organization. Identify operational obstacles to compliance; work with other employees to identify and implement solutions.

7. Coordinate the review and maintenance of South Country policies, assisting employees as needed to ensure that annual review and revision of policies are completed in a timely manner. Assist with the revision of South Country corporate compliance and HIPAA-related policies. Assist with policies and programs that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation.

8. Coordinate and assist with the completion of compliance reports for submission to regulators. Assist the Compliance Officer with periodic revision of South Country's corporate compliance program, annual work plan, Risk Assessments and Annual Program Integrity Report in light of changes in the organization's needs or in applicable federal and state regulations.

9. Provide support and assistance to Compliance and Government Relations Manager related to regulatory and contractual reporting to meet expected timelines, compliance monitoring activities, subrogation cases, and investigative activities. Provide support to Compliance Auditor related to monitoring and auditing of external entities and internal business functions to ensure compliance with applicable State and Federal laws and regulations.

10. Other duties assigned within the scope, responsibility and requirements of the job.

QUALIFICATION REQUIREMENT

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. This individual must have a high degree of integrity, effective time management, organization, and prioritization skills and must have strong self-initiative, self-motivation and the ability to exercise independent judgment. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

LANGUAGE SKILLS

Must be able to read and write in English. Must have the ability to read, understand and interpret regulations, legislation and contract language effectively and the ability to effectively present information and conduct staff training. Must have a high degree of interpersonal skills, influencing, coaching, problem solving, and communication.

MATHEMATICALTICAL SKILLS

Demonstrated ability to analyze, interpret, and validate complex data from multiple sources using mathematical, statistical, and analytical techniques. Proficient in identifying trends, discrepancies, and patterns to support compliance monitoring, investigations, reporting, and decision-making.

ACCURACY

High attention to detail is required to fulfill the requirements of this position. Errors and omissions may result in the inability of members to access health care services and result in contractual and regulatory non-compliance, which is likely to include financial sanctions to the organization.

REASONING ABILITY

Must understand cause and effect relationships and be able to draw conclusions from data, regulatory requirements, and past practice.

PHYSICAL DEMANDS

The physical demands described represent those that must be met by an employee to successfully perform the essential functions of this job. Where possible, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to sit. The employee is occasionally required to stand; walk; use hands to navigate office equipment, (i.e. computer, telephone, etc.), office supplies and reach with hands and arms.

The employee would rarely lift and/or move up to 5 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus.

CONTACTS/RELATIONSHIPS

This position periodically participates in meetings with local, state and federal regulatory entities, business partners, and TPAs and this position may occasionally travel to outside meetings with contractors, other health plans, regulatory entities and third-party administrators.

This position works closely with all departments within the organization and must be able to maintain a high degree of confidentiality within those departments. This person must also have the ability to maintain productive relationships with all levels of staff and management.

FINANCIAL IMPACT
In most cases, this position does not have full authority to act or to make decisions without gaining prior direction or permission in dealing with corporate compliance-related issues. In most cases, decisions should be made in collaboration with the Compliance Officer.