Senior SIU Compliance Analyst
Posted
Position Purpose
The Senior SIU Compliance Analyst supports the Special Investigations Unit’s compliance with federal and state fraud, waste, and abuse (FWA) program integrity requirements across multiple states. This role serves as a subject matter expert for SIU regulatory reporting, audit readiness, regulatory interpretation, and documentation standards. The position partners with SIU leadership, Compliance, Legal, operational teams, external regulatory agencies, law enforcement, and contracted partners to ensure accurate reporting, effective oversight, timely issue resolution, and audit-defensible SIU processes.
Essential Functions
The Senior SIU Compliance Analyst supports the Special Investigations Unit’s compliance with federal and state fraud, waste, and abuse (FWA) program integrity requirements across multiple states. This role serves as a subject matter expert for SIU regulatory reporting, audit readiness, regulatory interpretation, and documentation standards. The position partners with SIU leadership, Compliance, Legal, operational teams, external regulatory agencies, law enforcement, and contracted partners to ensure accurate reporting, effective oversight, timely issue resolution, and audit-defensible SIU processes.
Essential Functions
- In coordination with SIU leadership, conduct quality reviews and audits of FWA files to evaluate accuracy, completeness, timeliness, and adherence to departmental standards and regulatory requirements. Collect, analyze, monitor, and validate data and work activities to identify gaps, support corrective action, and maintain audit-defensible documentation. Coordinate with SIU leadership, internal stakeholders, external regulatory agencies, law enforcement, and contracted partners as needed to support ongoing requirements and ad hoc requests.
- Interpret regulatory guidance and lead implementation of compliant SIU processes. Develop, implement, and maintain process improvements, departmental policies, procedures, methodologies, and monitoring activities to support compliance with applicable laws, regulations, contractual requirements, and organizational standards. Review and monitor adherence to documented plans and recommend corrective action when gaps are identified.
- Prepare, validate, and coordinate timely submission of required SIU reports to federal and state regulatory agencies, including CMS, OIG, MFCU, Medicaid agencies, and other applicable oversight entities. Ensure reporting is accurate, complete, timely, and supported by appropriate documentation. Support internal and external audits, including CMS, Medicaid Program Integrity, HSAG, and related regulatory reviews.
- Maintain current knowledge of laws, regulations, contractual requirements, and regulatory guidance impacting health plan SIU operations, fraud, waste, and abuse oversight, health insurance delivery, and reimbursement. Apply regulatory requirements to daily work, provide guidance to internal partners, and support training or education related to SIU compliance expectations.
- Lead development and refinement of SIU policies, procedures, job aids, tools, and workflows to improve consistency, efficiency, and regulatory compliance. Identify process gaps, recommend solutions, and support implementation of corrective actions to mitigate compliance and audit risk.
- Manage and support complex projects related to SIU regulatory compliance across multiple programs and states. Identify best practices, evaluate applicability to SIU operations, develop recommendations and action plans, and communicate findings, risks, and outcomes clearly to SIU leadership and cross-functional stakeholders.
Minimum Requirements
- Bachelor's Degree or equivalent in Business, health care operations, nursing, law or other related area; or equivalent. Master's Degree preferred.
- 7 years of relevant experience in health care compliance, SIU, audit, regulatory analysis, or regulatory reporting.
- 5 years of demonstrated experience with FWA regulations and program integrity requirements, including CMS, OIG, Medicaid, MFCU, or related oversight programs is preferred
- Advanced analytical, problem-solving and documentation skills
- Legal or regulatory field; healthcare focus desirable
- Project management/program development and implementation
- Proven ability to produce audit-defensible work products and lead regulatory deliverables.
- Experience with CMS or state program integrity audits or responses.
Group Health Cooperative of Eau Claire complies with applicable Federal civil rights laws and does not discriminate, exclude or treat candidates less favorably on the basis of race, color, national origin (including limited English proficiency and primary language), age, disability, or sex (including sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity; and sex stereotypes).
The Cooperative is committed to fostering a caring and compassionate environment while ensuring that individual differences are valued. The Cooperative is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. It is essential that all employees and members feel secure and welcome, that the opinions and contributions of all individuals are respected and that all voices are heard.
This full time position offers an outstanding benefit package, including three weeks of vacation the first year, a generous retirement plan, health and dental insurance, a wellness program, and much more! If you are interested in working for an organization focused on a team atmosphere and is dedicated to providing exceptional service submit your resume today! Send resume to: resumes@group-health.com. Group Health Cooperative of Eau Claire is an affirmative action and equal opportunity employer.
The Cooperative is committed to fostering a caring and compassionate environment while ensuring that individual differences are valued. The Cooperative is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. It is essential that all employees and members feel secure and welcome, that the opinions and contributions of all individuals are respected and that all voices are heard.
This full time position offers an outstanding benefit package, including three weeks of vacation the first year, a generous retirement plan, health and dental insurance, a wellness program, and much more! If you are interested in working for an organization focused on a team atmosphere and is dedicated to providing exceptional service submit your resume today! Send resume to: resumes@group-health.com. Group Health Cooperative of Eau Claire is an affirmative action and equal opportunity employer.