Overview:
The compliance analyst for the Grievance & Appeals (G&A) department plays a key support role
in ensuring the department maintains compliance with regulatory, accreditation, and internal
standards. Under the direction of the G&A Compliance Manager, this role is responsible for
assisting with policy and the procedure maintenance, audit preparation and support, and
oversight of delegated entities. The compliance analyst also plays a critical role in identifying
process and quality improvement opportunities through data analysis and trending of grievance
and appeal cases. This is a dynamic and multifaceted position that supports various compliance
activities to maintain organizational readiness for internal audits, external reviews - such as
Centers for Medicare & Medicaid Services (CMS), California Department of Health Care
Services (DHCS), and National Committee for Quality Assurance (NCQA), and delegate
oversight.

Responsibilities:

• Analyzes G&A data to identify trends, root causes, and opportunities for process

improvement.

• Develops actionable insights based on data analysis to improve member satisfaction,

quality of care, quality of service, and operational efficiency.

• Supports the Compliance Manager in preparing and compiling monthly and quarterly

reports on department performance, trends, and key metrics.

• Assists with regulatory reporting to state and national agencies, ensuring accuracy and

timeliness.

• Collaborates with reporting analysts to review and validate data used for regulatory and

internal reports.

• Assists in the preparation and coordination of internal and external audits, including

gathering documentation and conducting pre-audit activities.

• Collaborate with the Compliance Manager to ensure department operations remain in

compliance with CMS, DHCS and NCQA requirements.

• Monitors grievance trends and collaborates with leadership to propose improvements to

department processes.

• Reviews and analyzes reports from delegated entities to ensure compliance with

grievance and appeals processes.

• Participates in the annual audit of delegated entities and assists with follow-up actions as

needed.

• Supports quality improvement initiatives by identifying areas for operational

enhancements based on data analysis.

• Collaborates with the Compliance Manager on special projects related to audits,

reporting, and regulatory compliance.

• Maintains accurate records and documentation for all regulatory, audit, and compliancerelated activities.
• Other duties as assigned

Qualifications:

EDUCATION AND EXPERIENCE

Bachelor’s degree in Healthcare Administration, Business
Administration, Public Health, Data Science, or related field; 3-4 years
of experience in the healthcare or managed care, with a focus on
grievance and appeals, compliance, or regulatory reporting preferred.
Experience with Medi-Cal, DHCS, NCQA, CMS, or other regulatory
healthcare environment preferred. An equivalent combination of
education and experience may be considered.
Special Skills, Licenses and Certifications
Working knowledge of Medi-Cal, CMS, DHCS and/or NCQA
regulations and standards. Highly proficient in applicable business
software applications including PC usage, Microsoft Word,
PowerPoint, Excel, and typing speed of 40 wpm. Valid California
Driver’s License and proof of current automobile insurance compliant
with Partnership’s policies are required to operate a vehicle and travel
for company business

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

• Analyzes G&A data to identify trends, root causes, and opportunities for proces