Compliance Specialist

Advantage Healthcare Services•Huntington Beach, CA

7d•Onsite

About The Position

The Compliance & Billing Specialist supports the organization's pharmacy compliance, licensing, credentialing, and reimbursement functions by ensuring regulatory requirements, payer expectations, and internal standards are accurately executed and maintained. This role serves as a key operational partner to Compliance, Pharmacy Operations, Revenue Cycle, and Credentialing teams to support licensing activities, billing compliance, audit readiness, reimbursement requirements, and ongoing regulatory compliance. The ideal candidate combines strong administrative discipline with knowledge of pharmacy operations, licensing regulations, healthcare reimbursement, medical billing, pharmacy claims processing, and regulatory documentation.

Requirements

Associate's degree in Healthcare Administration, Business Administration, Compliance, Pharmacy Technology, or related field.
3+ years of healthcare, pharmacy, compliance, licensing, credentialing, medical billing, or reimbursement experience.
Knowledge of healthcare and pharmacy regulatory requirements.
Strong attention to detail and document management skills.
Excellent organizational and project coordination abilities.
Strong analytical and problem-solving skills.
Ability to research and summarize regulatory requirements and operational procedures.
Effective written and verbal communication.
Ability to manage multiple priorities and deadlines.
Advanced Microsoft Excel, Word, Outlook, and reporting skills.

Nice To Haves

Understanding of medical billing, pharmacy billing, claims processing, prior authorization, and reimbursement practices highly preferred.
Bachelor's degree in Healthcare Administration, Business, Public Health, Compliance, or related field.
Certified Pharmacy Technician (CPhT) certification.
Experience in specialty pharmacy, behavioral health pharmacy, or multi-state pharmacy operations.
Experience supporting audits, licensing programs, or pharmacy reimbursement activities.

Responsibilities

Assist with all phases of pharmacy licensing and registration activities, including applications, renewals, amendments, and ownership changes.
Maintain accurate licensing records, databases, expiration tracking, and supporting documentation.
Coordinate submissions with Boards of Pharmacy, DEA, state agencies, Medicare, Medicaid, and other regulatory bodies.
Monitor regulatory deadlines and ensure timely renewals and reporting obligations.
Conduct research on evolving state and federal pharmacy regulations.
Maintain audit-ready licensing documentation and records.
Research, support, and monitor pharmacy and medical billing processes (e.g., claims submission, reimbursement, billing documentation) for compliance with payer, contractual, and regulatory requirements.
Assist with internal and third-party audits of pharmacy claims, authorizations, billing records, and supporting clinical documentation.
Help identify reimbursement risks, denials trends, and compliance concerns.
Monitor adherence to payer policies, reimbursement guidelines, and contract requirements.
Assist with implementation of billing compliance controls and corrective action plans.
Assist with internal audits and monitoring activities related to licensing, billing, reimbursement, credentialing, and compliance.
Gather and organize documentation for regulatory reviews, payer audits, accreditation surveys, and compliance assessments.
Track corrective actions and support remediation efforts.
Maintain compliance evidence repositories and audit logs.
Assist in developing and maintaining policies, procedures, workflows, and job aids.
Support compliance education and training initiatives.
Ensure operational changes resulting from regulatory or payer updates are communicated and documented.
Maintain accurate records of compliance activities and training completion.
Partner with Pharmacy Operations, Revenue Cycle, Credentialing, Quality, and Compliance teams.
Serve as a resource regarding licensing requirements, billing compliance standards, and reimbursement guidelines.
Escalate compliance concerns, audit findings, or identified risks to leadership.
Support special projects related to compliance program development and operational readiness.
Maintain compliance dashboards, trackers, and reporting metrics.
Monitor license expiration dates, audit findings, corrective action status, and reimbursement trends.
Generate reports to support compliance monitoring and leadership reviews.
Ensure data accuracy within licensing and compliance systems.