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Medical Mutual · 1 day ago

Sr. RAPS Compliance Analyst

Toledo, OH

Full-time

Hybrid

Senior Level

5+ years exp

Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. The Sr. RAPS Compliance Analyst will implement and manage daily operations of Risk Adjustment compliance for the Company’s Medicare Advantage and Qualified Health Plan programs, ensuring adherence to regulatory requirements and operational policies.

Health CareHealth InsuranceInsuranceLife Insurance

Culture & Values

H1B Sponsor Likely

Responsibilities

Participates in the tracking and completion of required RADV audit procedures, including data collection and submission. Participates in mock auditing and ongoing monitoring of First Tier, Downstream and Related entities (FDRs), as well as department vendor oversight and monitoring

Triages vendor operational and compliance issues and questions received from all areas of the department and organization, understands the underlying intent of the questions, and researches and analyzes to provide responses and recommendations. Escalates compliance issues or concerns as necessary

Reviews and analyzes various materials for compliance with regulatory and operational guidelines and how they impact operational processes; coordinates or performs any required approvals and/or submission to regulatory bodies or others if required

Creates, tracks, and validates Incident Reports and Corrective Action Plans issued to internal business owners, as well as vendors

Prepares for audits (internal, external, mock, or regulatory) and due diligence activities. May include the collection, preparation, review, and submission of information, data, and documents to requestors, regulators, or auditors; accurate tracking; recordkeeping; rescheduling or coordinating facilities; and creating/delivering presentations

Attends all relevant industry trainings and presentations (REGTAP, HHS, AHIP, TARSC, CMS, etc.)

Networks with and assists business owners and other staff regarding regulations specific to their operational responsibilities

Performs other duties as assigned

Collects, analyzes, interprets and documents information as part of preparing reports, including activities associated with preparation for any audits including those by independent third parties, Health and Human Services (HHS) or CMS

Creates and manages oversight of policies and procedures to ensure regulatory compliance is being met

Maintains knowledge of regulatory guideline changes and how they impact operational processes. Monitors developments and changes transmitted through Regtap for ACA/RADV and the Health Plan Management System (HPMS) that impact data validation requirements and brings to the attention of management

Manages the development, tracking and completion of required RADV audit protocols and required data collection and submission for filings, including first tier/downstream and related entities (FDR) roles in data collection. Leads mock audits; develops and implements quality assurance into risk adjustment programs. Leads annual RADVs. Reviews and monitors FDR role in producing data for audits

Ensures consistent interpretation of regulatory guidance across multiple departments and compilation of data for audits

Manages issuance and coordination of internal and vendor incident and corrective action plan management for risk adjustment operations, including validation audit of all remediation action plans

Networks with and assists business owners and other staff regarding regulations specific to their data collection and submission work. Works closely with internal business and IT areas and manages activities with third party IVA/IVC as regulations require

Prepares work papers and exemplars as needed or required by HHS/CMS and independent third parties

Responds to requests for information about the compliance program from outside regulatory entities. Responds to requests for RADV audits from HHS/CMS and independent third parties

Performs other duties as assigned

Qualification

Healthcare complianceMedicare Advantage knowledgeRisk Adjustment Data ValidationCertified ComplianceEthics ProfessionalAdvanced Microsoft Office skillsData analysisCMS audit proceduresHealth insurance operationsProject management skills

Required

Bachelors Degree in Business Administration, Healthcare Administration or related field

Equivalent education and experience directly related to the role may substitute for a degree

3 years of experience in healthcare compliance, preferably including exposure to Medicare Advantage or Part D

Knowledge of statutory and federal regulations that affect health insurance products, specifically Medicare Advantage and Qualified Health Plan (ACA)

Intermediate to advanced Microsoft Office skills; familiarity with LAN/WAN applications and SQL, QMF, and or other data extract methods

Understanding of operational, financial, and regulatory controls and risks and the ability to apply fundamental concepts to policies and processes

Knowledge of standard audit procedures and best practices

5 years progressive experience with healthcare compliance which includes 3 years in Risk Adjustment Data Validation (RADV) data collection or data analytic activities

Preferred

Certified Compliance and Ethics Professional (CCEP) or certification in healthcare compliance a plus

Certified in Healthcare Compliance preferred

Comprehensive knowledge of RADV requirements for Medicare Advantage and ACA Plans and the ability to apply concepts to operations

Knowledge of health insurance operations compliance risk areas and best practices

Knowledge of CMS audit procedures

Advanced Microsoft Office skills; familiarity with LAN/WAN applications

Strong project management skills

Company

Medical Mutual

Glassdoor4.1

Medical Mutual Provides and administers health benefits for citizens in Ohio.

Founded in 1934

Cleveland, Ohio, USA

1001-5000 employees

http://www.medmutual.com

H1B Sponsorship

Medical Mutual has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

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Trends of Total Sponsorships

2025 (18)

2024 (18)

2023 (17)

2022 (15)

2021 (24)

2020 (16)