Compliance Specialist

The Compliance Specialist supports the organization’s healthcare compliance and quality programs, ensuring adherence to all applicable federal and state laws, regulations, and regulatory guidance. This role works closely with the Vice President of Compliance to operationalize the compliance program, monitor regulatory and quality-related risk, and promote a culture of ethical conduct and continuous improvement.

What You’ll Do

Compliance Program Support

• Support the design, implementation, and ongoing maintenance of the organization’s healthcare compliance program in alignment with OIG and DOJ Compliance Program Guidance.
• Assist in operationalizing the seven elements of an effective compliance program, including policies and procedures, training, monitoring, auditing, reporting, and enforcement.
• Serve as a key resource to internal stakeholders on compliance-related questions and issues, providing guidance to translate regulatory requirements into actionable organizational practices.

Quality Program Support

• Support compliance and quality oversight for Enhanced Care Management (ECM) and Palliative Care programs in alignment with federal, state, and payer requirements.
• Monitor regulatory and contractual requirements while tracking evolving guidance impacting program operations, care delivery, and documentation standards.
• Conduct audits, monitoring, and QAPI activities, including metric tracking, trend analysis, and support for corrective action plans.
• Collaborate cross-functionally to address compliance risks, support audit readiness, and integrate quality and compliance standards into program workflows.

Regulatory Monitoring & Risk Management

• Monitor federal and state healthcare laws and regulations, including Anti-Kickback Statute, Stark Law, False Claims Act, HIPAA, and applicable state healthcare regulations.
• Track DOJ and OIG enforcement actions, advisory opinions, special fraud alerts, and compliance guidance, and assess applicability to organizational operations.
• Conduct compliance risk assessments and help identify, document, and address compliance risks, including fraud, waste, and abuse (FWA), enforcement trends, government oversight, and internal audits.
• Support regulatory change management by tracking new or updated laws, regulations, and enforcement trends, including monitoring requirements for potential new markets.

Auditing, Monitoring & Investigations

• Assist with compliance audits, monitoring activities, and reviews to assess adherence to internal policies and regulatory requirements.
• Support internal investigations related to potential compliance concerns, including documentation, issue tracking, and corrective action plans.
• Coordinate responses to compliance inquiries, audits, and regulatory requests, as directed by Compliance Leadership.
• Maintain investigation and audit documentation in accordance with DOJ and OIG standards and expectations.

Training, Education & Communication

• Assist in developing and delivering compliance training and education programs for employees, contractors, and leadership.
• Promote awareness of compliance reporting mechanisms and non-retaliation standards.
• Draft compliance communications, guidance documents, and policy updates, and support implementation of compliance guidance into day-to-day operations.

General Duties

• Maintain organized, audit-ready records.
• Collaborate with internal departments to streamline workflows and improve regulatory preparedness.
• Stay informed on state and federal regulatory requirements.
• Support ad-hoc compliance and quality initiatives, including policy updates, audits, and corrective action implementation, as needed.