Compliance Analyst

Compliance Analyst Los Gatos, CA Job Details $50 - $60 an hour 5 hours ago Qualifications Performance dashboard reports Collaborate with healthcare professionals Revenue cycle management Dashboard development Appeals Compliance risk assessment Medical coding compliance oversight Medicare Audit report preparation Healthcare Administration Regulatory compliance Healthcare fraud investigations Insurance claim appeals processing Bachelor's degree in business Certified Fraud Examiner Compliance audits & assessments Training material drafting Implementing healthcare compliance training programs Mid-level Risk mitigation strategy implementation State healthcare regulations High school diploma or GED Certified Professional Coder CMS regulatory compliance Analysis skills Policy & process development Bachelor's degree Centers for Medicare and Medicaid Services (CMS) Medical insurance appeals management Data interpretation Insurance investigations Bachelor's degree in healthcare administration Business Administration Healthcare policy development Training & development Business Communication skills Internal audits Full Job Description El Camino Health Medical Network is currently seeking a talented Compliance Analyst to join our growing healthcare team!

Pay :

$50.00/hr-$60.00/hr

Location :

Los Gatos, CA (Hybrid-Must be Local)

Summary:

The Compliance Analyst monitors and evaluates coding, billing, and documentation practices to ensure alignment with federal and state regulations, payer policies, and internal standards. The role supports risk mitigation, conducts investigations, and partners with clinical and operational teams to improve compliance across the medical network.

Essential Functions:

Regulatory Monitoring and Interpretation Track and interpret regulatory changes affecting professional services, including

CMS, OIG, AMA

CPT, and commercial payer policies. Assess the impact of new rules on coding, billing, and documentation workflows. Develop guidance and compliance alerts to communicate regulatory updates to stakeholders. Professional Coding and Billing Compliance Review Conduct internal audits of CPT, HCPCS, and ICD10CM coding for professional services across multiple specialties. Review E/M services for correct level selection, timebased coding, and medical decisionmaking alignment. Evaluate modifier usage, medical necessity, and documentation sufficiency. Identify trends in errors, denials, and potential compliance risks. Investigations and Risk Mitigation Support investigations related to billing irregularities, payer inquiries, and potential fraud, waste, or abuse. Collaborate with legal, compliance, and revenue cycle teams to develop corrective action plans. Assist in preparing responses to payer audits, including documentation requests and appeals. Data Analysis and Reporting Analyze coding and billing data to identify patterns, anomalies, and areas of risk. Prepare compliance dashboards, audit summaries, and performance reports for leadership. Monitor key indicators such as denial trends, coding accuracy rates, and audit outcomes. 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 subjectmatter 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. AAPC credentials such as

CPC , CPMA

, or CPCO . Experience in compliance, auditing, or revenue cycle operations within a physician practice or health system. Familiarity with federal regulations such as Medicare billing rules, OIG guidance, and statespecific requirements. 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:

Experience with multispecialty professional coding audits. Background in denial management, payer appeals, and compliance investigations. Knowledge of risk adjustment, quality reporting, and reimbursement methodologies (e.g., RBRVS). Experience developing compliance education or training materials. The Compliance Analyst monitors and evaluates coding, billing, and documentation practices to ensure alignment with federal and state regulations, payer policies, and internal standards. The role supports risk mitigation, conducts investigations, and partners with clinical and operational teams to improve compliance across the medical network.

Essential Functions:

Regulatory Monitoring and Interpretation Track and interpret regulatory changes affecting professional services, including

CMS, OIG, AMA

CPT, and commercial payer policies. Assess the impact of new rules on coding, billing, and documentation workflows. Develop guidance and compliance alerts to communicate regulatory updates to stakeholders. Professional Coding and Billing Compliance Review Conduct internal audits of CPT, HCPCS, and ICD10CM coding for professional services across multiple specialties. Review E/M services for correct level selection, timebased coding, and medical decisionmaking alignment. Evaluate modifier usage, medical necessity, and documentation sufficiency. Identify trends in errors, denials, and potential compliance risks. Investigations and Risk Mitigation Support investigations related to billing irregularities, payer inquiries, and potential fraud, waste, or abuse. Collaborate with legal, compliance, and revenue cycle teams to develop corrective action plans. Assist in preparing responses to payer audits, including documentation requests and appeals. Data Analysis and Reporting Analyze coding and billing data to identify patterns, anomalies, and areas of risk. Prepare compliance dashboards, audit summaries, and performance reports for leadership. Monitor key indicators such as denial trends, coding accuracy rates, and audit outcomes. 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 subjectmatter 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. AAPC credentials such as

CPC , CPMA

, or CPCO . Experience in compliance, auditing, or revenue cycle operations within a physician practice or health system. Familiarity with federal regulations such as Medicare billing rules, OIG guidance, and statespecific requirements. 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:

Experience with multispecialty professional coding audits. Background in denial management, payer appeals, and compliance investigations. Knowledge of risk adjustment, quality reporting, and reimbursement methodologies (e.g., RBRVS). Experience developing compliance education or training materials.

Location:

Silicon Valley Medical Development •

SVMD Operations Schedule:

Temporary, Days, 8:00am-5:00pm