Quality & Compliance Specialist
Noble Hearts HR Consulting•Greenville, NC
•$60,000 - $95,000•Remote
About The Position
A growing behavioral health organization serving North Carolina Medicaid members is seeking an experienced Quality & Compliance Specialist to lead quality assurance, regulatory compliance, utilization review, and audit readiness. This role is ideal for a proactive compliance professional who understands NC Medicaid, LME/MCOs, Tailored Plans, DHHS requirements, clinical documentation, and behavioral health billing compliance. You do not wait for an audit to uncover a problem. You know how to identify risks, strengthen processes, and help teams correct concerns before they become findings.
Requirements
- Bachelor's degree in Human Services, Healthcare Administration, Behavioral Health, Social Work, or a related field; equivalent relevant experience may be considered
- At least three years of experience in behavioral health Medicaid compliance, QA/QI, utilization review, or a related role with a North Carolina provider
- Strong knowledge of NC Medicaid behavioral health requirements, including Clinical Coverage Policy 8A
- Understanding of outpatient mental health and substance use services, documentation standards, staffing, and credentialing
- Experience with NC LME/MCOs, Tailored Plans, NCTracks, and authorization systems
- Experience preparing for Medicaid, MCO, DHHS, or similar regulatory audits
- Experience developing and monitoring corrective action plans
- Strong understanding of clinical documentation and billing compliance
- Ability to translate regulatory requirements into practical policies and workflows
- Strong communication, organization, and analytical skills
- Ability to work independently and follow compliance concerns through resolution
- Reliable transportation and successful completion of required Medicaid exclusion screenings
Nice To Haves
- Behavioral health compliance or QA/QI leadership
- Substance use treatment programs
- NC TOPPS and NC IRIS reporting
- EHR implementation or optimization
- CARF or similar accreditation standards
- Policy development and compliance training
- Compliance dashboards and reporting tools
- CHC, CPHQ, or similar quality or compliance certification
Responsibilities
- Conduct clinical documentation reviews and ongoing chart audits
- Manage the organization's Quality Assurance and Quality Improvement Plan
- Prepare for Medicaid, MCO, DHHS, DHSR, and other regulatory audits
- Identify compliance risks and develop corrective action plans
- Monitor corrective actions through completion
- Track documentation trends and recurring compliance concerns
- Monitor regulatory updates from NC Medicaid, DHHS, Tailored Plans, and LME/MCOs
- Maintain compliance policies, procedures, and staff guidance
- Review service authorizations and reauthorizations to prevent coverage gaps
- Partner with billing to address documentation, denial, and reimbursement concerns
- Confirm that billed services are supported by compliant documentation
- Manage client grievances and compliance-related complaints
- Monitor required reporting, including NC IRIS and NC TOPPS
- Support compliant EHR workflows and system improvements
- Provide leadership with regular compliance findings, trends, and recommendations
Benefits
- health, dental, and vision coverage
- paid time off
- mileage reimbursement for required travel
- professional development support
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
