Compliance & Investigations Manager

PT Solutions•,

4d•$90,000 - $95,000

About The Position

The Compliance & Investigations Manager supports the organization’s Compliance and Risk Management functions through the oversight and execution of complex investigations, operational risk reviews, and regulatory compliance assessments. This role is responsible for conducting thorough investigations related to compliance hotline reports, risk management events, billing and coding concerns, regulatory matters, and operational issues across multiple healthcare settings. The Compliance & Investigations Manager is expected to move beyond transactional investigation management by performing deep-dive analyses to identify root causes, operational vulnerabilities, systemic trends, and opportunities for process improvement. This position partners closely with operational leaders, Human Resources, Legal, Revenue Cycle, Clinical Leadership, and other departments to develop corrective action plans and risk mitigation strategies designed to reduce organizational risk and strengthen regulatory compliance.

Requirements

Bachelor’s degree in Healthcare Administration, Nursing, Business Administration, Compliance, Legal Studies, or related field.
Minimum of five (5) years of experience in healthcare compliance, healthcare investigations, risk management, auditing, revenue integrity, or related healthcare regulatory role.
Demonstrated experience conducting complex healthcare investigations independently.
Strong working knowledge of: Healthcare billing and coding, CMS regulations, HIPAA/privacy requirements, Fraud, waste, and abuse concepts, Healthcare operational workflows.
Experience working within multiple healthcare settings such as outpatient clinics, physician practices, hospital-based departments, ambulatory care, or rehabilitation services.
Strong analytical, interviewing, investigative documentation, and problem-solving skills.
Ability to identify systemic operational risks and recommend meaningful corrective actions.

Responsibilities

Conduct complex compliance, operational, privacy, billing, coding, and risk management investigations across multiple healthcare settings.
Manage investigations originating from the Compliance Hotline, Risk Management Event Reporting System, leadership referrals, regulatory concerns, and internal audits.
Conduct witness interviews, review documentation, analyze supporting evidence, and prepare detailed investigation reports and summaries.
Ensure investigations are conducted thoroughly, objectively, confidentially, and in accordance with organizational policies and regulatory expectations.
Track and trend investigation activity to identify recurring operational, compliance, and patient safety risks.
Perform detailed root cause analyses to identify underlying process failures, operational breakdowns, and systemic vulnerabilities contributing to events or allegations.
Develop actionable recommendations and corrective action plans aimed at reducing future risk exposure and improving operational performance.
Collaborate with operational leaders to implement process improvements and monitor effectiveness of mitigation strategies.
Identify trends and emerging risk areas requiring proactive intervention or monitoring.
Review allegations and event reports for potential regulatory, billing, coding, fraud/waste/abuse, HIPAA/privacy, or operational compliance concerns.
Analyze healthcare billing and coding documentation for potential compliance or reimbursement risk.
Assist in the evaluation of operational practices to ensure compliance with CMS requirements, healthcare regulations, accreditation standards, and organizational policies.
Support regulatory readiness activities and operational compliance reviews across outpatient, physician practice, and hospital-based healthcare settings, including HOPD environments when applicable.
Prepare executive-level summaries, investigation findings, trend reports, and recommendations for leadership review.
Partner with Compliance, Risk Management, Revenue Cycle, Legal, Human Resources, Operations, and Clinical teams on investigations and corrective actions.
Participate in organizational risk assessments, auditing activities, and compliance initiatives as needed.
Support the organization’s overall compliance and risk reduction strategy through proactive operational engagement and analysis.
Review injury reports: Examine incident files, worker statements, and supervisor reports to initiate the claims process.
Conduct investigations: Interview claimants, supervisors, and witnesses to collect necessary factual evidence.
Evaluate claims history: Check prior claims data to identify pre-existing conditions or potential patterns of fraud.
Act as liaison: Serve as the primary point of contact between injured teammates, management, insurance carriers, third party administrator and legal teams.
Facilitate return-to-work: Coordinate light-duty assignments and modified work plans with human resources and safety officers.
Adhere to timelines: Complete initial contacts and statutory form filings within mandated legal periods (often 24 to 48 hours).
Maintain electronic documentation: Log updates, diary dates, and case milestones inside a paperless risk management database.
Support legal counsel: Gather and organize discovery materials to assist attorneys with formal hearing preparation.
Attend legal proceedings: Represent the employer or carrier at mediations, settlement conferences, and appeals board hearings.
Analyze claim trends: Generate statistical reports for risk managers to identify frequent safety hazards and cost-saving opportunities.