We are currently hiring a Managed Care Compliance Specialist! If you are highly detail-oriented, analytical, and skilled at interpreting and applying complex regulations in a fast-paced environment, and value being part of a team that makes a difference, you may be the right person for the position! Apply today!
Classification: NON-EXEMPT | Status & Schedule: FULL-TIME, MONDAY – FRIDAY, 8AM – 5PM
Location: REMOTE, must reside in list of approved states (OR, TX, DE)
Salary: $22.00 - $28.00/HOURLY
Department: COMPLIANCE | Reports to: CHIEF COMPLIANCE & QUALITY OFFICER | Supervision Exercised: NON-SUPERVISORY
Job Purpose: Compliance Specialist
This position supports the organization’s Compliance Program and Fraud, Waste, and Abuse Prevent Plan through development and tracking of compliance monitoring activities, auditing support in internal, external, and provider audits, monitoring for state and federal and Coordinated Care Organization (CCO) Contract changes, maintaining a regulatory tracking log, compliance reviews of organization’s policies and procedures, documentation management, track corrective action plans with management and conduct follow up, assist with compliance and privacy investigations, and compliance education coordination, including maintaining records of completion, and supporting updates to training material and possibly assist with training development. This position assists in ensuring compliance with applicable federal and state laws, Medicaid Managed Care requirements, Oregon Health Authority (OHA) standards, Centers for Medicare & Medicaid Services (CMS) regulations, Health Insurance Portability and Accountability Act (HIPAA), Fraud, Waste, and Abuse (FWA) prevention requirements, contractual obligations, accreditation standards, and organizational policies to help promote ethical conduct, federal and state regulatory adherence, and organizational accountability by supporting compliance program operations, compliance reviews, reporting activities, training coordination, and ongoing regulatory readiness throughout the organization.
Qualifications, Education, & Experience
- Associate’s degree in healthcare administration, business administration, public administration, or related field, experience in lieu of education may be considered.
- Two years of experience in compliance, privacy, healthcare administration, auditing, quality assurance, program integrity, or related field.
- Experience working in a regulated healthcare environment preferred.
- Knowledge of healthcare compliance principles, HIPAA, Fraud, Waste, and Abuse (FWA), Medicaid, or regulatory requirements.
- Certified in Healthcare Compliance (CHC) through the Health Care Compliance Association (HCCA) Compliance Certification Board (CCB), or the ability to obtain within one year of hire.
Essential Responsibilities: Compliance Specialist
Compliance Monitoring & Auditing
- Assist with implementation and ongoing administration of the organizational Compliance Program and FWA Prevention Plan.
- Conduct routine compliance monitoring, auditing, and reporting activities related to:
- Fraud, Waste, and Abuse prevention.
- Federal and State regulatory compliance.
- Provider documentation and record review.
- Delegated entities and subcontractor oversight.
- HIPAA privacy and security requirements.
- Contractual and organizational compliance obligations.
- Review operational processes, records, and documentation to identify compliance risks, trends, deficiencies, or areas of vulnerability.
- Assist with preparation of audit tools, monitoring reports, audit summaries, corrective action tracking, and compliance related reporting dashboards.
- Track corrective action plans and monitor timely implementation of remediation activities and follow up actions.
- Maintain accurate documentation related to audits, investigations, monitoring activities, corrective actions, and compliance reviews.
Regulatory Compliance Support
- Comply with organization’s internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State and local regulations.
- Assist with monitoring changes in applicable federal, state, and local laws, regulations, and guidance impacting Medicaid Managed Care and Coordinated Care Organization (CCO) operations.
- Assist with review, revision, and maintenance of policies, procedures, and related documentation to support regulatory and contractual compliance.
- Support preparation activities for external audits, readiness reviews, accreditation reviews, and regulatory submissions.
- Assist with gathering, organizing, and maintaining documentation related to regulatory reporting requirements, audits, and information requests.
- Support compliance related communications and follow up activities with internal departments, providers, subcontractors, and regulatory agencies as directed.
Fraud, Waste, and Abuse Activities
- Support Fraud, Waste, and Abuse prevention, detection, monitoring, and reporting activities in accordance with organizational policies and regulatory requirements.
- Assist with preliminary reviews, documentation gathering, and tracking activities related to suspected compliance violations, FWA concerns, or potential areas of non-compliance.
- Identify and report potential high-risk findings, trends, or concerns to Compliance Leadership for further review and investigation.
- Maintain accurate and confidential investigation files, tracking logs, and related compliance documentation.
- Assist with monitoring and follow up activities related to FWA corrective actions and compliance resolutions.
Investigation & Incident Support
- Assist with intake, documentation, coordination, and tracking of compliance concerns, hotline reports, grievances, incidents, and potential regulatory issues.
- Participate in internal investigations, fact finding activities, and documentation reviews under the direction of Compliance Leadership.
- Assist with investigation tracking, follow up activities, corrective action monitoring, and resolution documentation.
- Maintain accurate, timely, and confidential documentation related to compliance activities, investigations, incidents, and follow up actions.
- Escalate potential compliance risks, significant findings, or unresolved concerns to Compliance Leadership as appropriate.
Training & Education
- Coordinate compliance training assignments and scheduling for employees, providers, contractors, board members, and delegated entities.
- Assist with development, distribution, and maintenance of compliance education materials, resources, and reference tools.
- Support organizational awareness and understanding of key compliance topics, including:
- Fraud, Waste, and Abuse (FWA) prevention.
- HIPAA privacy and security requirements.
- Regulatory requirements and expectations.
- Ethical business and operational practices.
- Provide support to staff regarding compliance training content and participation.
- Assist Compliance Leadership in identifying areas for additional education or awareness initiatives.
Committee & Administrative Support
- Assist with preparation of materials, reports, agendas, and minutes for Compliance Committee meetings, ensuring accurate and timely distribution to members.
- Maintain compliance records, logs, monitoring documentation, and organizational tracking systems in accordance with policy and regulatory requirements.
- Support data collection, analysis, and reporting for compliance program evaluation, performance metrics, and audit readiness.
- Assist in the preparation of presentations, dashboards, and summary reports for leadership or external reviewers as requested.
- Help coordinate committee communications, scheduling, and follow-up activities to support timely completion of action items.
- Provide administrative support for compliance initiatives, projects, and ad hoc requests from Compliance Leadership.
- Ensure all documentation and materials are maintained securely and confidentially, in compliance with HIPAA, regulatory, and organizational standards.
Quality & Process Improvement
- Participate in organizational quality improvement, risk mitigation, and compliance initiatives to support program integrity and operational excellence.
- Assist in identifying opportunities for operational improvement, enhanced regulatory compliance, and risk reduction within assigned areas of responsibility.
- Assist with implementation and standardization of compliance workflows, monitoring processes, and internal controls.
- Support process documentation and maintain accurate records to ensure consistency and regulatory readiness.
- Collaborate with departments to provide feedback on compliance trends, operational challenges, and potential improvements.
Confidentiality & Professional Conduct
- Maintain strict confidentiality of sensitive, protected, and privileged information, including personnel records, patient information, and compliance investigations.
- Conduct all duties in accordance with organizational values, ethical standards, and applicable federal, state, and contractual regulations.
- Promote a culture of compliance, accountability, and integrity throughout the organization by modeling ethical behavior and supporting staff understanding of regulatory expectations.
- Assist Compliance Leadership in reinforcing organizational policies, ethical business practices, and regulatory standards among employees, contractors, and providers.
- Handle sensitive communications, documentation, and reporting with discretion and professionalism at all times.
- Perform other duties as assigned.
Essential Responsibilities: ORGANIZATIONAL TEAM MEMBER
- Participate in quality and organizational process improvement activities when requested.
- Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities.
- Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner.
- Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization.
- Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations.
- Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications.
- Advance personal knowledge base by pursuing continuing education to enhance professional competence.
- Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards.
- Represent organization at meetings and conferences as applicable.
Knowledge, Skills, & Abilities:
- Knowledge of healthcare compliance principles, regulatory requirements, and industry standards.
- Understanding of Medicaid Managed Care, healthcare operations, and basic managed care concepts.
- Knowledge of and ability to adhere to all applicable federal and state laws and regulations, including HIPAA, Occupational Safety and Health Administration (OSHA), Fraud, Waste, and Abuse (FWA), Medicaid Managed Care requirements, and Oregon Health Authority (OHA) standards.
- Knowledge of Oregon Health Plan (OHP), MAP rules and regulations, and Coordinated Care Organization (CCO) metrics preferred.
- Understanding of evidence-based practices, healthcare populations, health equity, and access to care principles.
- Ability to interpret regulations, policies, contracts, audit findings, and corrective action plans.
- Excellent written, verbal, organizational, and interpersonal communication skills.
- Strong investigative, analytical, critical thinking, and problem-solving skills, including the ability to evaluate information, identify risks, and apply sound judgment within established guidelines and procedures.
- Demonstrate initiative in identifying problems and developing practical solutions. Ability to apply innovative, cost-conscious thinking to improve processes.
- Strong organizational skills and attention to detail, with the ability to prioritize multiple assignments and meet deadlines in a fast-paced environment.
- Demonstrate appropriate management of time. Ability to work independently and collaboratively across departments and with external partners.
- Make efficient use of available resources.
- Proficient in Microsoft Office Suite, Windows Operating System (OS), and compliance related systems.
- Awareness of Health Literacy, Trauma Informed Care, Cultural Awareness, Culturally and Linguistically Appropriate Services (CLAS) Standards, health equity principles, and language access practices, with the ability to work effectively and sensitively with diverse populations and individuals from varying cultural, social, and economic backgrounds.
- Knowledge and understanding of how the position contributes to departmental and organizational goals.
- Ability to report to work as scheduled and maintain flexibility to support operational needs.
- Ability to maintain confidentiality and handle sensitive or stressful situations professionally, effectively, and with discretion.
- Abide by organization’s policies and procedures at all times.
Working Conditions:
This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.
Work Condition: Remote work
Employee generally works within a remote work from home environment.
Travel may be required on occasion.
Hours of operations and specific staff scheduling may vary based on operational need.
Exposed to:
Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery or software, such as fax, copier, calculator, multi-line telephone system, or scanner.
May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information.
Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task.
Other Information:
This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of Advanced Health employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
