Compliance Specialist

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.

EDUCATION & EXPERIENCE

Required

• 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.