Compliance Specialist

PURPOSE OF THE POSITION: The Compliance Specialist is responsible for ensuring organizational adherence to all applicable Medicaid, state and federal regulations and guidelines. This role supports the development, implementation, and monitoring of compliance programs to mitigate risk and ensure ethical and legal conduct in all compliance-related operations.

REPORTS TO: Director of Compliance

I. SPECIFIC RESPONSIBILITIES

1. Monitor and interpret federal and state Medicaid regulations as well as other applicable rules and regulations to ensure organizational compliance.

2. Conduct internal audits and risk assessments related to Medicaid billing, documentation, and service delivery.

3. Develop and deliver training programs for staff on Medicaid compliance policies and procedures.

4. Investigate and respond to potential compliance issues, including reporting and corrective action planning.

5. Maintain documentation of compliance activities, including complaints, investigations, and outcomes.

6. Collaborate with legal, billing, and clinical departments to ensure integrated compliance efforts.

7. Assist in the preparation for external audits and respond to audit findings.

8. Stay current with changes in Medicaid laws and regulations and communicate updates to relevant stakeholders.

9. Support the development and revision of compliance policies and procedures.

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II. QUALIFICATIONS

· Bachelor’s degree in healthcare administration, public health, law, or a related field (Master’s preferred).

· Minimum of 3 years of experience in healthcare compliance, with a focus on Medicaid.

· Strong knowledge of Medicaid regulations, billing practices, and healthcare operations.

· Excellent analytical, organizational, and communication skills.

· Ability to manage multiple projects and meet deadlines.

· Certification in healthcare compliance (e.g., CHC, CHPC) preferred.