Compliance Specialist

• Supports and implements the organizations’ vision, mission, and values.

• Determines priorities and method of completing daily workload to ensure that all responsibilities are carried out in a timely manner.

• Fosters and promotes a culture of service excellence and accountability.

• Performs all job functions in a professional and courteous manner. Conduct is customer service oriented, professional, and objective. This includes answering all phone calls and emails timely and providing excellent customer service to internal and external customers.

• Performs job duties independently and exercises good judgment.

• Manages the organizations’ third-party vendor relations and contract administration to include review of contract documents, set-up of applicable software system, role assignment, security settings and overseeing the review/approval process.

• Manages the organizations’ document management systems to ensure corporate records, contracts, agreements, and other records are maintained in compliance with filing, access, destruction, and retention policies.  Manages and coordinates document/media clean up days.

• Promotes a heightened awareness and understanding of standards of conduct and ethics; new and existing compliance issues; related policies and procedures and use of reporting systems, including the compliance hotline.

• Oversees, maintains, manages, tracks, and assists in the preparation and revision of organizational policies and procedures.

• Coordinates compliance review and monitoring activities, including periodic reviews of departments.


• Assists with external audits and inspections conducted by contracted health plans and federal, state and county entities. Assists Director of Operations and Health Center Managers to prepare for audits and respond to resulting Corrective Action Plans (CAPs); reports and tracks status of CAPS.

• Promotes, develops, and conducts compliance training and education for all staff. Ensures that employees, independent contractors, and vendors are trained in the requirements of the compliance program. Monitors completion of compliance related trainings in organizations’ learning management systems and ensures completion.

• Maintains the company’s incident management system and is responsible for ensuring that departments are reporting, investigating, correcting, and closing incidents in a timely manner.

• Collaborates with other functional departments and Director of Risk & Compliance to resolve difficult compliance issues.

• Develops systems for tracking outcomes and ensuring that all governmental requirements are met.

• Maintains absolute confidentiality in all matters related to audits, investigations, incidents, or any potentially confidential matter.

• Maintains current knowledge of relevant compliance regulations, trends, and practices.

• Oversees grievance and incident management across all related departments and collaborates with other functional departments to ensure that all grievances and incidences are investigated and resolved in a timely and professional manner, while ensuring the privacy and confidentiality of patients, staff and providers. Reports patient-related incidents and grievances to the quality committee.

• Uses discretion while performing duties and responsibilities, while handling sensitive or confidential information and exercises good judgement.

• Complies with organizational policies and procedures.

• Composes neat, legible, complete, and accurate, documentation in a timely manner.

• Performs other duties as assigned.


• Must be willing and able to work at all locations as needed to meet patient care needs.


• Must be willing and able to work all business hours including evenings and weekends.


• Credentialing


• Participates in the development and implementation of process improvements for the system-wide credentialing process; prepares reports as required by regulatory and accrediting agencies, policies and standards.


• Conducts primary source verification, collects and validates documents to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards and organizational criteria.


• Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures. Files and maintains confidential credentialing and privileging files.


• Prepares, issues, electronically tracks and follows-up on appropriate verifications for efficient, high volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines.


• Follows-up on appointment letters, processes requests for additional privileges and explains the reasons/s for the condition/limitation/deferment. Maintains forms and templates, and credentialed staff information.


• Drives to various clinic and administrative locations to collect signatures, deliver documents, mail or ship, and/or collect forms, as needed.


• Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures. Files and maintains confidential credentialing and privileging files.

JOB KNOWLEDGE AND SKILLS:

• Demonstrates required knowledge, skills, and education for job functions.


• Demonstrates exceptional leadership skills and a high level of emotional intelligence.


• Demonstrates broad knowledge of and competency in compliance functions; demonstrates familiarity with healthcare laws, regulations and standards to include but not limited to HIPAA Privacy and Security, HRSA’s 19 Program requirements, Federal Tort & Claims Act, 340 B Drug, SB137, Generally Accepted Accounting Principles (GAAP).  Knowledge of audit and investigative tools, practices, and methodologies; insurance plan requirements and regulations.


• Demonstrates understanding of business and general computer controls in the following areas: clinical, accounting, billing, HR, payroll, credentialing, risk management, governance / risk and other relevant applications/systems.