SUMMARY:
Responsible for the leadership, management, and oversight of all provider network compliance functions for Wisconsin NEMT operations, ensuring transportation providers meet contractual, regulatory, credentialing, and operational requirements related to drivers, vehicles, and business operations. Oversees compliance monitoring, HIPAA-aligned practices, program integrity activities, and coordination of fraud, waste, and abuse investigations. Ensures accurate and timely reporting of incidents, accidents, compliance concerns, and regulatory matters while maintaining adherence to client, contractual, and company standards.
Position contingent upon award of contract.
POSITION LOCATION IS ON-SITE IN MADISON, WI.
ESSENTIAL FUNCTIONS:
- Oversee the execution, maintenance, and renewal of transportation provider agreements, ensuring compliance with contractual, regulatory, credentialing, and operational requirements.
- Build and maintain effective working relationships with clients, regulatory agencies, transportation providers, and internal departments to support compliance, communication, and operational objectives.
- Direct all aspects of provider network compliance operations, including credentialing, record maintenance, database management, field observations, vehicle inspections, and compliance monitoring activities.
- Verify and maintain current provider, driver, vehicle, insurance, certification, licensing, and training documentation to ensure compliance with contractual, regulatory, and company standards.
- Develop, implement, and maintain compliance policies, procedures, audit methodologies, monitoring tools, and reporting processes to assess and improve NEMT network compliance.
- Coordinate and conduct annual, bi-annual, monthly, random, and spot inspections of providers, vehicles, drivers, and attendants to ensure compliance with provider agreements and performance standards.
- Identify, investigate, analyze, and report compliance risks, deficiencies, trends, and areas of non-compliance; develop and implement corrective action plans and remediation strategies.
- Respond to alleged violations of laws, regulations, policies, procedures, and contractual requirements by conducting or coordinating investigations and recommending appropriate corrective actions.
- Investigate accidents, incidents, complaints, quality concerns, fraud, waste, and abuse allegations; perform root cause analyses and coordinate resolution efforts to minimize risk and potential liquidated damages.
- Monitor compliance activities across departments and collaborate with Operations, Finance, Quality Assurance, Provider Network, and Program Integrity teams to identify trends, mitigate risks, and improve performance.
- Serve as the primary liaison with clients, providers, and regulatory agencies regarding provider network compliance matters, audits, investigations, corrective actions, and performance expectations.
- Ensure compliance-related records, reports, photographs, videos, and supporting documentation are accurately maintained, uploaded, retained, and submitted within required timeframes and audit standards.
- Direct provider and employee compliance training initiatives, ensuring required training programs are developed, implemented, documented, and reinforced in accordance with contractual requirements.
- Supervise Compliance Operations Specialists, Compliance Field Officers, and related personnel by providing onboarding, training, coaching, performance evaluations, and corrective action as necessary.
- Ensure providers, drivers, attendants, and compliance personnel consistently perform in accordance with company standards, contractual requirements, and regulatory expectations.
- Oversee safety, security, and risk management programs, including incident review, accident response coordination, and compliance-related risk mitigation activities.
- Prepare, review, and submit compliance, audit, investigative, operational, and regulatory reports for senior leadership, clients, and government agencies.
- Coordinate with Finance and Operations to resolve reconciliation issues, payment discrepancies, and compliance-related documentation concerns.
- Serve as a subject matter expert on compliance requirements, advising leadership on regulatory changes, risk exposure, contract compliance, and process improvement opportunities.
- Perform other duties as assigned.
QUALIFICATIONS REQUIRED:
- Minimum of five (5) years of customer service experience.
- Minimum of three (3) years of compliance, risk management, regulatory oversight, or related experience.
- Minimum of two (2) years of supervisory or management experience.
- Five (5) years of experience in Non-Emergency Medical Transportation (NEMT), Emergency Medical Services (EMS), public transit, fleet management, or a related transportation environment preferred.
- Thorough knowledge of Medicaid NEMT regulations, contract compliance requirements, provider network oversight, and Department monitoring expectations.
- Demonstrated experience leading compliance monitoring programs, internal audits, inspections, corrective action plans, investigations, and documentation reviews.
- Experience managing provider credentialing, driver and vehicle compliance, training requirements, inspections, and time-sensitive renewals.
- Strong analytical, investigative, problem-solving, and decision-making skills, including the ability to identify and address compliance risks, fraud, waste, abuse, and operational deficiencies.
- Excellent written and verbal communication skills with the ability to prepare reports, communicate findings, coordinate corrective actions, and interact effectively with providers, clients, regulatory agencies, and internal stakeholders.
- Strong organizational skills with the ability to maintain accurate, audit-ready records, documentation, and compliance evidence.
- Proficiency with compliance management systems, reporting tools, Microsoft Office Suite, and other business applications.
- Ability to work independently and collaboratively across multiple departments, including Operations, Provider Network, Quality, Information Technology, and Finance.
- Ability to maintain professionalism, exercise sound judgment, and demonstrate a positive, customer-focused attitude.
- Must meet all contractual requirements applicable to NEMT drivers and compliance personnel.
- Certification or ability to obtain certification as an instructor in:
- Defensive Driving
- Passenger Assistance
- First Aid
- CPR
MINIMUM REQUIRED EDUCATION:
5+ years compliance risk, or program integrity leadership experience; NEMT of healthcare operations preferred.
Bachelor’s degree in business from an accredited College or University and/or commensurate experience in area of quality or compliance strongly preferred.
