Compliance Coordinator

PROMPTCARE COMPANIES INC•King of Prussia, PA

2d•Hybrid

About The Position

The Compliance Coordinator supports the Intake & Resupply organization by ensuring clinical and administrative documentation meets Medicare, CMS, and payer compliance requirements. This role reviews medical records, payer medical policies, and regulatory guidelines to determine eligibility, coverage, and medical necessity. The Compliance Coordinator plays a key role in audit readiness, authorization support, and appeals by identifying documentation gaps, interpreting payer requirements, and partnering with internal teams to maintain compliant, high-quality patient care.

Requirements

Prior experience in Medicare Advantage or managed care organizations
Certification in Case Management (CCM), Utilization Review (CPUR), or equivalent
Experience with audits, appeals, and regulatory compliance
Administrative focus
Minimum 2–5 years of experience (acute care, managed care, or Medicare populations preferred)
Strong knowledge of Medicare Parts A, B, C, and/or D
Experience with utilization management, case management, or clinical review
Familiarity with CMS regulations, medical necessity criteria, and evidence-based guidelines (InterQual, MCG, or similar)
Strong analytical, documentation, and communication skills
Proficiency with electronic medical records and clinical review systems
Ability to interpret medical records, particularly chart notes including test results, diagnosis, medical verbiage pertaining to diagnosis.
Must be able to interpret and comprehend published payer medical policies
Determine Contraindicators within published medical policies for acceptance while maintaining compliance practices

Responsibilities

Evaluate clinical information to determine member eligibility, coverage, and medical necessity in accordance with Medicare regulations, CMS guidelines, and organizational policies
Ensure compliance with federal requirements while supporting high-quality, cost-effective patient care
Provide feedback and guidance for a written appeals process to overturn authorization denials
Effectively identify missing or non-complaint documentation required under CMS guidelines and published medical policies for governmental and commercial payers
Monitor and ensure compliance with relevant laws and regulations
Ensure all facility-based licensure is maintained
Monitor and evaluate the performance of the existing Licensure/Registered Agent Vendor
Identify areas of non-compliance and assist in developing corrective action plans
Keep the Chief Compliance Officer aware of changes to relevant laws and regulations
Assist with providing compliance training to staff
Assist with Compliance Department activities
Prepare and submit reports to management on compliance activities
Perform other duties as assigned by the supervisor

Benefits

Comprehensive Medical, Dental, and Vision Package
401(k) Plan with Company Match
Generous PTO: Vacation, Sick Time, Personal Days, and Paid Holidays
Life Insurance: Standard coverage with optional enhancements
Employee Assistance Program: Free counseling and coaching sessions
Emotional Well-being and Work-Life Balance Resources
Short & Long-Term Disability: Company-paid with optional supplements
Accidental Death and Dismemberment Insurance
FSA and HSA: Manage healthcare expenses
Commuter Spending Programs
Volunteer and Engagement Opportunities
Employee Referral Bonuses
Exclusive Discounts on entertainment, travel, and various other supplemental and cellphone plans