Health Care Network Compliance Senior Specialist

CBIZ•Tallahassee, FL

1d•Hybrid

About The Position

Myers and Stauffer is seeking an observant, detail-oriented, and reliable Compliance Senior Specialist to support the Network Adequacy team. This position involves evaluating adequate health plan provider networks through onsite visits, telephonic surveys of healthcare providers, and assessing the accuracy of provider directories. As a Health Care Network Compliance Senior Specialist, you will play a vital role in ensuring healthcare members receive access to quality care, while supporting compliance with regulatory standards. This is an excellent opportunity for those with a keen eye for detail and a passion for improving the healthcare experience.

Requirements

High School diploma or GED

Nice To Haves

Bachelor’s degree in health policy, health care administration, health information, public health, social services, criminal justice, business, or related field preferred.
Ability to adhere to strict confidentiality guidelines and maintain professionalism.
Proficiency in data entry tools and Microsoft Office Suite (Word, Excel).
Strong organizational and time management skills to manage assignments effectively and meet deadlines.
Strong written and verbal communication skills.
Bilingual in English and Spanish.
Reliable transportation to conduct onsite evaluations.
Ability to travel up to 30% of time in the Miami-Dade area, based on client and business needs.
Prior experience in any of the following roles: secret shopper, healthcare compliance, auditing, program integrity, health plan provider/member enrollment, customer care call center.
Familiarity with healthcare networks, provider enrollment processes, and/or patient services.
Willingness to provide unbiased feedback based on observations rather than personal opinions or biases.
Ability to work flexible hours to accommodate various assignments.

Responsibilities

Review, summarize, and apply Federal and State Medicaid and/or Medicare policies and regulations, ensuring operational and program compliance.
Conduct onsite and telephonic surveys (as a "secret shopper") to assess the availability, accessibility, and quality of healthcare providers in the health plan network.
Evaluate compliance with network adequacy standards, including geographic coverage and timeliness of care.
Use provided evaluation criteria, checklists, and protocols to document observations accurately and comprehensively.
Maintain detailed and organized records of all evaluations, ensuring confidentiality and adherence to reporting standards.
Submit clear and well-documented reports summarizing survey outcomes, patterns, and issues encountered during secret shopping activities.
Collaborate with the team to improve processes, share insights, and contribute to actionable recommendations for enhancing network performance.
Ability to adapt to using tools, such as Qualtrics survey platform, 8x8 Computer-Assisted Telephone Interviewing (CATI) platforms and various AI models
Support stakeholder engagement activities; supporting trainings and training materials as needed.
Maintain professional behavior while conducting assessments in both onsite and telephonic settings.
Additional responsibilities as assigned.