Compliance Specialist

DETROIT WAYNE Integrated HEALTH Network • Detroit, MI

7d • Hybrid

About The Position

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.

Requirements

• Knowledge of health care fraud and abuse laws (e.g., False Claims Act, Stark Law, Anti‑Kickback Statute) and associated penalties
• Knowledge of general health care laws, regulations, and standards
• Knowledge of governmental compliance regulations
• Knowledge of DWIHN policies, procedures, and practices
• Knowledge of DWIHN provider network and community resources
• Knowledge of Michigan Mental Health Code
• Knowledge of MDHHS policies, rules, regulations, and procedures
• Knowledge of Federal policies, rules, regulations, and procedures as related to DWIHN
• Knowledge of NCQA requirements and the accreditation process
• Knowledge of contracting policies and procedures
• Knowledge of Quality Management and Improvement principles and practices
• Knowledge of HIPAA compliance and privacy standards
• Skills in corrective action planning and implementation
• Skills in assessment and investigative techniques
• Skills in organization and planning
• Skills in attention to detail and accuracy
• Skills in analytical, logical, and critical thinking
• Skills in time management and prioritization
• Skills in report writing and documentation
• Skills in problem‑solving and decision‑making
• Strong interpersonal and teamwork abilities
• Proficiency with computer and data analysis tools
• Ability to communicate clearly and professionally, both orally (including presentations) and in writing
• Ability to maintain confidentiality and adhere to ethical standards
• Ability to work collaboratively and effectively with others across departments and disciplines
• Ability to respect and effectively engage with an ethnically, linguistically, culturally, economically, and socially diverse population
• Ability to exercise sound judgment and reasoning abilities
• 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.
• One (1) year of professional experience performing investigations and responsibilities including at least two (2) years of experience working in a healthcare setting.
• A valid State of Michigan Driver’s License with a safe and acceptable driving record.

Nice To Haves

• Certification as a Healthcare Compliance Officer (CHC) through the Health Care Compliance Association.

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.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level