Quality & Compliance Specialist

Confidential Employer | North CarolinaRemote with Monthly Travel to Eastern North CarolinaFull-Time or Part-Time/Fractional OpportunityA growing behavioral health organization serving North Carolina Medicaid members is seeking an experienced Quality & Compliance Specialist to lead quality assurance, regulatory compliance, utilization review, and audit readiness.This role is ideal for a proactive compliance professional who understands NC Medicaid, LME/MCOs, Tailored Plans, DHHS requirements, clinical documentation, and behavioral health billing compliance. You do not wait for an audit to uncover a problem. You know how to identify risks, strengthen processes, and help teams correct concerns before they become findings.What You'll DoConduct clinical documentation reviews and ongoing chart audits

Manage the organization's Quality Assurance and Quality Improvement PlanPrepare for Medicaid, MCO, DHHS, DHSR, and other regulatory audits

Identify compliance risks and develop corrective action plans

Monitor corrective actions through completion

Track documentation trends and recurring compliance concerns

Monitor regulatory updates from NC Medicaid, DHHS, Tailored Plans, and LME/MCOsMaintain compliance policies, procedures, and staff guidance

Review service authorizations and reauthorizations to prevent coverage gaps

Partner with billing to address documentation, denial, and reimbursement concerns

Confirm that billed services are supported by compliant documentation

Manage client grievances and compliance-related complaints

Monitor required reporting, including NC IRIS and NC TOPPSSupport compliant EHR workflows and system improvements

Provide leadership with regular compliance findings, trends, and recommendations

What We're Looking ForBachelor's degree in Human Services, Healthcare Administration, Behavioral Health, Social Work, or a related field; equivalent relevant experience may be considered

At least three years of experience in behavioral health Medicaid compliance, QA/QI, utilization review, or a related role with a North Carolina provider

Strong knowledge of NC Medicaid behavioral health requirements, including Clinical Coverage Policy 8AUnderstanding of outpatient mental health and substance use services, documentation standards, staffing, and credentialing

Experience with NC LME/MCOs, Tailored Plans, NCTracks, and authorization systems

Experience preparing for Medicaid, MCO, DHHS, or similar regulatory audits

Experience developing and monitoring corrective action plans

Strong understanding of clinical documentation and billing compliance

Ability to translate regulatory requirements into practical policies and workflows

Strong communication, organization, and analytical skills

Ability to work independently and follow compliance concerns through resolution

Preferred ExperienceBehavioral health compliance or QA/QI leadership

Substance use treatment programsNC TOPPS and NC IRIS reportingEHR implementation or optimizationCARF or similar accreditation standards

Policy development and compliance training

Compliance dashboards and reporting toolsCHC, CPHQ, or similar quality or compliance certification

CompensationFull-Time: $60,000–$95,000 annually, depending on experience and qualifications.Benefits include health, dental, and vision coverage; paid time off; mileage reimbursement for required travel; and professional development support.Part-Time/Fractional Contractor: $35–$75 per hour, depending on experience and scope.Location and TravelThis is a remote-first position for candidates residing in North Carolina. Travel to Eastern North Carolina is required at least once per month and occasionally for audits, site reviews, training, and leadership meetings.Candidates located in Eastern North Carolina are strongly preferred. Reliable transportation and successful completion of required Medicaid exclusion screenings are required.Ready to Apply?Please submit your resume and a brief summary of your experience with North Carolina Medicaid behavioral health compliance, quality assurance, and regulatory audits.The employer's identity will be shared with qualified candidates as they advance through the recruitment process.#BehavioralHealthJobs #NCMedicaid #HealthcareCompliance #QualityAssurance #NorthCarolinaJobs

Job Posted by ApplicantPro