Compliance Specialist

AllCare Management Services•Grants Pass, OR

31d•$26 - $30•Hybrid

About The Position

The Compliance Specialist is responsible for assisting in the oversight of an enterprise-wide Corporate Compliance Program to detect, correct and prevent violations of Federal and State laws, rules, or regulations. The position is responsible for assisting the Chief Compliance Officer with implementing, maintaining and monitoring the compliance program elements that includes investigations, policies, standards, workforce training, and awareness of general compliance requirements, reporting, and investigating concerns of FWA. This position will help in the evaluation of the FWA and Compliance Program. The Compliance Specialist will report to the Chief Compliance Officer in the investigation of suspected violations and in the development and oversight of corrective action plans. The Compliance program involves a continuous process of adhering to legal, ethical and professional standards applicable to AllCare employees, Board of Governors, providers, contractors, temporary employees, consultants and subcontractors. The Compliance Specialist will cooperate and assist in submitting appropriate referrals and case documentation to enforcement agencies such as the Medicaid Fraud Unit (MFCU), Office of Program Integrity (OPI), Office of Inspector General (OIG), Department of Justice (DOJ), Centers for Medicaid and Medicare Services (CMS) and the Oregon Health Authority (OHA) for auditing, monitoring and oversight of external subcontractors (delegates).

Requirements

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others.
Ability to perform each essential duty satisfactorily.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.
One to two years related experience and/or training in criminal justice, fraud management, investigations, or healthcare administration.
Knowledge of CPT Codes, ICD-10 Codes, Medicare Guidelines, OIG Work Plan priorities, Oregon Health Plan Contract Requirements, HIPAA, FWA and Compliance CFRs, Regulations and Statutes.
Familiarity with the Healthcare industry.
Exceptional writing, editing, and proofreading skills.
Excellent organization and time-management skills.
Excellent computer skills, including the Microsoft Office Suite (Outlook, Word, PowerPoint, and Excel).
Knowledge of and compliance with HIPAA regulations.
Knowledge of project management and/or change management.
Demonstrate accountability, inspiring trust and confidence from others.
Self-resolve most conflicts or misunderstandings with minimal need for direct supervision.
Work with high initiative, energy and effectiveness in a fast-past environment.
Effectively and professionally communicate with team members and customers.
Collaborate within a multidisciplinary, diverse team to provide professional service.
Prioritize and organize work according to competing timelines.
Allocate your time so that you can complete tasks within established deadlines.
Maintain an attentive and empathetic demeanor.
Maintain a high degree of professionalism and confidentiality.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Ability to write reports, business correspondence, and procedure manuals.
Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry.
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Job requires specialized computer skills.
Must be adept at using various applications including database, spreadsheet, report writing, project management, graphics, word processing, presentation creation/editing, communicate by e-mail and use scheduling software.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and work with several abstract and concrete variables.
The employee must occasionally lift and/or move up to 10 pounds.
While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
The employee is occasionally required to stand; walk and reach with hands and arms.
The noise level in the work environment is usually moderate.
The employee must be able to work onsite for all scheduled shifts.
The employee may be able to work from a home office occasionally, as needed with leader’s approval.
The employee must be able to travel locally, as needed.

Nice To Haves

Bachelor's degree (BA) from a four-year college or university in criminal justice, fraud management, or healthcare administration preferred.
Valid Oregon Driver’s License and vehicle insurance.

Responsibilities

Investigate all suspected cases of FWA.
Conducts investigations, utilizing data analytics, forensic tools and conduct thorough fact-finding inquiries.
Write investigations reports to be submitted to OHA, MFCU and OPI.
Maintain a comprehensive knowledge of applicable federal and state laws, regulations and other requirements.
Assist in audits conducted by outside regulatory agencies.
Assist in audits conducted by AllCare Health of its subcontractor (delegates) or First Tier Entities.
Upholds the highest level of confidentiality in verbal, written or electronic communications pertaining to Compliance, FWA or HIPAA Privacy and Security referrals.
Manage the investigative process for potential compliance violations, including fraud, abuse, conflicts of interest, and other regulatory breaches.
Oversee the identification, reporting, and investigation of compliance concerns, and provide guidance on risk mitigation strategies.
Utilize investigative techniques, data analytics, and forensic tools to identify suspicious activity and conduct thorough fact-finding inquiries.
Prepare investigative reports with findings, conclusions, and recommendations for corrective actions.
Act as the organization’s subject matter expert on healthcare regulations, including but not limited to Stark Law, Anti-Kickback Statute, False Claims Act, and others.
Assists in conducting the annual enterprise-wide risk assessment and program evaluations.
Assist the Chief Compliance Officer in the development of risk-based compliance monitoring work plan and protocols.
Actively participate in the Compliance program, FWA and HIPAA Privacy & Security activities.
Accurately log and maintain records of reported or discovered compliance concerns.
Provide guidance to internal staff on appropriate interpretation and application of internal and regulatory policy/procedures.
Use sound logic and reasoning to identify opportunities to improve processes.
Effectively communicate with peers and other departments on compliance matters, work collaboratively in a team environment with a spirit of cooperation.
Maintains punctual, regular and predictable attendance.
Respectfully takes directions from Chief Compliance Officer and Corporate Legal Counsel.
Meets all required training including continuing education for certifications such as, but not limited to: CFE, CHC, AHFI, CPC, and those listed in Relias Learning Module System (LMS).
Performs other duties as assigned.
Works collaboratively in a team environment with a spirit of cooperation.
Respectfully takes direction from leadership.
Meets all required training including those listed in Relias Learning Module System (LMS).