Compliance Specialist

Principal Duties And Responsibilities

• Conduct FWA Investigations: Manage investigations related to suspected fraud, waste, and abuse within the provider network.
• Data Gathering & Analysis: Collect, review, and analyze relevant documents, data, claims, medical records, and other evidence to assess compliance with applicable regulations.
• Interviews: Perform interviews with staff, providers, witnesses, or other relevant parties as part of the investigation process.
• Compliance Reviews & Audits: Perform targeted audits and reviews to detect patterns indicative of potential FWA.
• Research Regulations & Policies: Maintain working knowledge of state, federal, and internal regulations, policies, and billing requirements related to FWA.
• Documentation & Case Management: Maintain accurate and thorough records of investigation activities, findings, and outcomes in compliance with applicable policies and regulations.
• Reporting: Prepare comprehensive investigation reports and summaries for internal review, external regulators, or enforcement authorities.
• Corrective Action Plans: Recommend and/or collaborate with staff and providers to implement corrective action plans and training for identified deficiencies.
• Collaboration: Partner with internal departments (Managed Care Operation, Quality, Clinical) and external enforcement authorities (e.g., OIG, Attorney General) as needed.
• Educational & Prevention: Assist in training staff and providers on FWA prevention, detection, and compliance best practices.
• Regulatory Monitoring: Stay current with changes in state and federal regulations and enforcement trends related to FWA.

Knowledge, Skills And Abilities (ksa’s)

• Knowledge: Health care fraud and abuse laws (e.g., False Claims Act, Stark Law, Anti-Kickback Statute) and associated penalties; General health care laws, regulations, and standards; Governmental compliance regulations; DWIHN policies, procedures, and practices; DWIHN provider network and community resources; Michigan Mental Health Code; MDHHS policies, rules, regulations, and procedures; Federal policies, rules, regulations, and procedures as related to DWIHN; NCQA requirements and the accreditation process; Contracting policies and procedures; Quality Management and Improvement principles and practices; HIPAA compliance and privacy standards.
• Skills: Corrective action planning and implementation; Assessment and investigative techniques; Organization and planning; Attention to detail and accuracy; Analytical, logical, and critical thinking; Time management and prioritization; Report writing and documentation; Problem-solving and decision-making; Strong interpersonal and teamwork abilities.
• Abilities: Communicate clearly and professionally, both orally (including presentations) and in writing; Maintain confidentiality and adhere to ethical standards; Work collaboratively and effectively with others across departments and disciplines; Respect and effectively engage with an ethnically, linguistically, culturally, economically, and socially diverse population; Exercise sound judgment and reasoning abilities.

Required Education

• A Bachelor’s degree in Criminal Justice, Business Administration, Public Administration, Accounting / Finance, Healthcare Administration, Human Resources, Health Information Management, Law / Legal Studies, Social Services / Social Work.

Required Experience

• One (1) year of professional experience performing investigations and responsibilities including at least two (2) years of experience working in a healthcare setting.

Preferred PIHP and CMHSP experience in Compliance

• Premier Healthcare Partnerships Program (PIHP) and Community Mental Health Services Program (CMHSP) experience in Compliance.
• Preferred CMH and/or Behavioral Health Experience.

Required License(s)

• A valid State of Michigan Driver’s License with a safe and acceptable driving record.
• Certification as a Healthcare Compliance Officer (CHC) through the Health Care Compliance Association (Preferred).