Compliance Specialist

Job Details

Description

Competencies & Skills Needed:

Adaptability: Effectively navigates changing regulatory requirements, competing priorities, and evolving operational needs while maintaining accuracy and follow-through.Analytical Thinking: Reviews claims, documentation, trends, and compliance data to identify risk, root causes, and practical corrective actions.Attention to Detail: Maintains a high degree of accuracy when conducting audits, reviewing documentation, tracking findings, and supporting regulatory requirements.Communication: Translates regulatory, payor, and compliance requirements into clear, practical guidance for cross-functional partners.Organizational Effectiveness: Effectively prioritizes audits, monitoring activities, follow-up items, reporting, and recurring compliance responsibilities.Team Collaboration: Partners effectively across Compliance, Revenue Cycle, Operations, Sales, Legal, and other business functions to support shared compliance objectives.Resourcefulness: Identifies practical solutions to compliance concerns and independently researches requirements, issues, and emerging risks.

Essential Duties And Responsibilities

Compliance Auditing, Monitoring & Investigations

Perform routine and targeted compliance audits across claims, billing, coding, documentation, reimbursement, denials, payment adjustments, recoupments, refunds, and patient financial responsibility.Review operational and revenue-cycle activity for adherence to federal and state requirements, payor rules, accreditation standards, company policy, and the Code of Conduct.Identify trends, documentation gaps, billing errors, reimbursement discrepancies, potential overpayments, and other emerging compliance risks.Document audit findings, quantify identified risk where appropriate, and escalate significant concerns to compliance leadership.Support internal investigations involving compliance concerns, billing or documentation issues, privacy matters, complaints, or potential regulatory violations.Conduct root-cause analysis and partner with business owners to develop, track, and validate corrective and preventive actions.Perform follow-up reviews to confirm remediation is effective and sustained.Support organizational readiness for payor audits, governmental reviews, accreditation activities, and related document requests.

Compliance Program Support

Assist with the development, review, maintenance, and administration of compliance policies, procedures, work instructions, and supporting documentation.Support compliance training, education, attestations, exclusion screening, privacy/security activities, and third-party oversight processes.Monitor regulatory, payor, and industry developments and help translate changes into practical operational guidance.Maintain organized compliance records, audit documentation, investigation materials, corrective-action tracking, and other program evidence.Partner with Compliance leadership and cross-functional stakeholders to strengthen day-to-day compliance processes and controls.Support periodic compliance risk assessments and work-plan activities based on identified organizational risk.Maintain current knowledge of healthcare compliance requirements and industry best practices through continuing education and professional development.

Reporting & Operational Responsibilities

Prepare concise compliance reports, dashboards, trend summaries, findings, and recommendations for compliance leadership and business stakeholders.Track audit results, corrective actions, recurring issues, and key compliance indicators to support ongoing monitoring and leadership visibility.Coordinate with Revenue Cycle, Operations, Sales, Legal, Finance, IT, and other functions to obtain documentation, resolve findings, and support compliance initiatives.Handle sensitive and confidential information with appropriate discretion and professionalism.Perform additional duties and special projects as assigned.

Required

EDUCATION & EXPERIENCE

Bachelor’s degree in healthcare administration, business, compliance, finance, accounting, health information management, or a related field; equivalent relevant experience may be considered.Minimum of 3 years of experience in healthcare compliance, auditing, billing, coding, revenue cycle, reimbursement, healthcare operations, or a related field.Working knowledge of healthcare compliance concepts, billing and reimbursement processes, documentation requirements, and regulated healthcare operations.Demonstrated ability to independently conduct reviews or audits, analyze findings, identify trends and root causes, and communicate practical recommendations.Strong written communication, organization, documentation, analytical, and follow-through skills.

Preferred

Experience within DME/HME, DMEPOS, medical device, or another highly regulated healthcare environment.Experience with claims and documentation auditing, overpayment identification, corrective-action monitoring, payor audits, or healthcare investigations.Relevant certification such as CHC, CPC, CPMA, RHIA, CIA, or equivalent preferred.Experience supporting multi-state healthcare operations, accreditation requirements, or cross-functional compliance programs.