Compliance Specialist

Job Description

Job Description

COMPLIANCE SPECIALIST

Pay Grade: 7

Under the general supervision of the Vice President of Compliance & Privacy Officer, the Compliance Specialist is responsible for conducting investigations and audits related to fraud, waste, and abuse within the DWIHN provider network. This role includes performing targeted reviews, gathering and analyzing information, and applying relevant regulations, policies, and internal controls to assess compliance. The Compliance Specialist also supports the implementation of policies, procedures, and control measures to ensure that DWIHN and its providers adhere to applicable regulatory and ethical standards.

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.
• Education & 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.
• Privacy & Confidentiality: Maintain confidentiality of sensitive information and adhere to privacy and data security requirements throughout the investigation process.

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
• Proficiency with computer and data analysis tools

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.

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)

WORKING CONDITIONS :

Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. The position is a hybrid role, and candidates must be based in Michigan.

This description is not intended to be a complete statement of job content, rather to act as the essential functions performed. Management retains the discretion to add or change the position at any time.

Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process.

The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer