Clinical Compliance Analyst, RN

FirstHealth of the Carolinas, Inc.•Pinehurst, NC

11d

About The Position

The Clinical Compliance Analyst, RN supports enterprise-wide compliance initiatives, audits, investigations, and regulatory monitoring. The position reports to the Corporate Compliance Officer and has no supervisory responsibilities. It coordinates with departments, management, providers, and employees throughout the organization, including clinical and administrative staff across locations and departments. The analyst supports the organization’s corporate compliance plan and policy development, performs audits and chart reviews, monitors clinical documentation, coding, billing, and medical necessity, and assists with investigations and corrective actions. The role also prepares and maintains audit and compliance documentation, communicates findings and recommendations, and develops or delivers education and guidance on compliance, documentation, coding, and regulatory requirements.

Requirements

Bachelor’s degree in nursing (BSN).
Active North Carolina Registered Nurse (RN) license.
One of the following: 3–5 years of progressive nursing management experience, or 10+ years of experience in a similar clinical compliance, quality, utilization management, or regulatory role.
Proficiency with Microsoft Word, Microsoft Excel, and EPIC.
Proficiency with office automation, personal computers, email, and reporting applications.
Working knowledge of HIPAA privacy and security requirements.
Understanding of healthcare compliance standards and regulatory expectations.
Strong verbal and written communication skills.
Ability to work with multiple departments and non-FHC clinics such as PMC, PSC, and CEA.
Commitment to customer service and positive team relationships.
Ability to educate, influence, and collaborate with clinical and administrative staff.
Analytical and statistical problem-solving abilities, including reviewing data, identifying trends, and evaluating compliance risks.
Ability to interpret findings and make practical recommendations.
Ability to identify operational or compliance issues and develop creative, effective solutions.
Sound judgment and critical thinking abilities.
Strong attention to detail and accuracy in audit documentation.
Ability to prioritize multiple projects and responsibilities, meet deadlines, and manage time effectively.
Ability to identify compliance risks and develop practical corrective actions.
Ability to provide unbiased evaluations.

Nice To Haves

Knowledge of Medicare and Medicaid coverage guidelines.
Knowledge of Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
Knowledge of healthcare reimbursement practices.
Knowledge of CPT coding and medical coding principles.

Responsibilities

Assist in developing, updating, and maintaining compliance with policies and procedures.
Support implementation and ongoing monitoring of the organization’s corporate compliance plan.
Evaluate audit processes and compliance goals and recommend improvements.
Apply structured problem-solving methods to compliance and operational issues.
Plan and perform financial, operational, and compliance audits.
Analyze audit data, evaluate findings, and communicate results objectively and impartially.
Monitor medical necessity, clinical documentation, coding, and billing practices.
Conduct inpatient and outpatient chart reviews.
Participate in compliance monitoring activities and internal audits.
Assist with investigations involving suspected non-compliance and support implementation of corrective actions.
Maintain confidentiality throughout audits and investigations.
Prepare reports related to audits, monitoring activities, investigations, and regulatory requirements.
Provide information to support management decision-making, risk reduction, and operational effectiveness.
Document audit testing, findings, recommendations, and supporting work papers thoroughly.
Maintain accurate records and compliance documentation.
Develop educational materials related to compliance, documentation, coding, and regulatory requirements.
Provide compliance-related guidance to employees, leadership, and medical staff.
Support organization-wide training on ethical conduct, legal requirements, and regulatory standards.
Promote a culture of compliance and accountability.