Regulatory Compliance Specialist

Modivcare

2d•$50,000 - $65,000•Onsite

About The Position

The Regulatory Compliance Specialist coordinates and manages the timely, accurate, and secure response to external regulatory audits, investigations, and requests for information involving the organization's Mobility and Personal Care Services businesses. The role serves as a project lead for requests from entities such as Medicaid Fraud Control Units (MFCUs), Unified Program Integrity Contractors (UPICs), the U.S. Department of Justice (DOJ), Office of Inspector General (OIG), Attorneys General, state Medicaid agencies, and Medicaid managed care organizations (MCOs). The Specialist coordinates with Legal, Compliance, Operations, Claims, Clinical/Personal Care, Finance, Provider Management, IT, and other stakeholders to identify, retrieve, validate, organize, and prepare responsive information, including claims data, trip/service records, billing and payment data, provider records, contracts, rate information, policies, procedures, and supporting documentation. This position requires strong project management, audit, data analysis, written communication, and judgment skills, with the ability to manage multiple high-priority matters and regulatory deadlines simultaneously.

Requirements

Bachelor's degree in business, healthcare administration, health information management, compliance, accounting, criminal justice, public administration, or a related field preferred; equivalent relevant experience may be considered.
Three (3) plus years of progressively responsible experience in healthcare audit, regulatory response, compliance, investigations, project management, healthcare operations, or a related field required.
Direct experience responding to government or regulatory requests from entities such as MFCU, UPIC, DOJ, OIG, Attorneys General, state Medicaid agencies, or MCOs strongly preferred.
Experience managing audits or information requests involving claims data, trip/service records, billing or payment data, provider records, or other healthcare documentation strongly preferred.
Experience in Medicaid, NEMT/mobility, personal care services, home care, managed care, or another regulated healthcare environment preferred.
Experience using Excel for data analysis, reconciliation, filtering, pivot tables, lookups, and preparation of supporting schedules preferred.
Project management, audit, compliance, healthcare data, or fraud/waste/abuse training or certification is a plus.
Demonstrated experience managing external audits, regulatory inquiries, investigations, information requests, or similar compliance-driven projects in a healthcare or other highly regulated environment.
Strong project management skills, including the ability to establish workplans, manage competing priorities, track dependencies, drive action items, and meet firm regulatory or contractual deadlines.
Working knowledge of Medicaid programs, healthcare claims, healthcare operations, fraud, waste and abuse concepts, and regulatory oversight processes; experience with NEMT, mobility, personal care, home care, or related services strongly preferred.
Ability to interpret detailed requests, break complex requirements into actionable tasks, and determine the records, data, and subject matter expertise needed to support a complete response.
Strong analytical skills with the ability to review, reconcile, and validate claims, service, trip, billing, payment, provider, and other operational data across multiple systems and sources.
Advanced proficiency with Microsoft Excel and Microsoft Office applications; experience working with large datasets, reporting tools, or data visualization platforms preferred.
Excellent written communication skills, including the ability to draft clear, concise, fact-based summaries and responses for internal and external audiences.
Strong attention to detail and sound judgment when handling sensitive, confidential, regulated, and potentially investigative information.
Ability to work independently, exercise appropriate escalation judgment, and collaborate effectively with Legal, Compliance, Operations, Claims, Finance, IT, Provider Management, and other cross-functional teams.
Ability to maintain organized workpapers, version control, document indexes, supporting schedules, and audit trails sufficient to demonstrate how a response was developed and supported.
Professional communication skills and the ability to manage high-priority requests in a fast-paced environment with changing requirements and tight deadlines.

Nice To Haves

Bachelor's degree in business, healthcare administration, health information management, compliance, accounting, criminal justice, public administration, or a related field preferred
Direct experience responding to government or regulatory requests from entities such as MFCU, UPIC, DOJ, OIG, Attorneys General, state Medicaid agencies, or MCOs strongly preferred.
Experience managing audits or information requests involving claims data, trip/service records, billing or payment data, provider records, or other healthcare documentation strongly preferred.
Experience in Medicaid, NEMT/mobility, personal care services, home care, managed care, or another regulated healthcare environment preferred.
Experience using Excel for data analysis, reconciliation, filtering, pivot tables, lookups, and preparation of supporting schedules preferred.
Project management, audit, compliance, healthcare data, or fraud/waste/abuse training or certification is a plus.
Working knowledge of Medicaid programs, healthcare claims, healthcare operations, fraud, waste and abuse concepts, and regulatory oversight processes; experience with NEMT, mobility, personal care, home care, or related services strongly preferred.
Advanced proficiency with Microsoft Excel and Microsoft Office applications; experience working with large datasets, reporting tools, or data visualization platforms preferred.

Responsibilities

Serve as the primary coordinator and project lead for external audit, regulatory, investigative, and information requests from MFCUs, UPICs, DOJ, OIG, Attorneys General, state Medicaid programs, MCO clients, and other authorized oversight entities.
Intake and assess each request to understand its scope, applicable business area, population, date range, requested records, response format, due dates, and required stakeholders; establish a documented workplan and response timeline.
Manage multiple concurrent requests from initiation through final submission, maintaining an audit/request tracker, status reporting, action items, dependencies, deliverables, and deadlines to ensure timely completion.
Coordinate cross-functional teams to obtain responsive records and data from Mobility and Personal Care Services operations, including trip logs, service records, claims and encounter data, billing/payment information, provider records, contracts, rate sheets, policies, procedures, and related documentation.
Perform detailed reviews of retrieved records and datasets for completeness, accuracy, consistency, relevancy, and responsiveness to the request; identify gaps, discrepancies, duplicates, or exceptions and coordinate resolution with the appropriate business owners.
Prepare and organize response packages, including data files, supporting records, exhibits, document indexes, summaries, chronologies, and draft written responses, consistent with request requirements and internal review standards.
Coordinate with Legal and Compliance on matters requiring legal interpretation, privilege considerations, regulatory strategy, escalation, or review of proposed responses; promptly escalate potential compliance, fraud, abuse, or material operational issues identified during the response process.
Communicate professionally with internal stakeholders and, when authorized, external requestors to clarify information needs, resolve questions, confirm response requirements, and manage submission logistics and deadlines.
Maintain a secure, organized repository of request-related materials, correspondence, workpapers, source data, final response packages, and submission records in accordance with records retention, privacy, security, and document control requirements.
Use Microsoft Excel and other reporting or data tools to analyze large datasets, identify trends or anomalies, reconcile information across systems, and develop clear supporting schedules for regulatory and audit responses.
Support follow-up requests, supplemental documentation, interviews, and additional questions that arise after an initial submission, maintaining version control and a complete record of communications and deliverables.
Identify opportunities to improve the organization's processes for responding to government investigations, regulatory audits, client audits, and information requests, including standardization, tracking, reporting, documentation, and turnaround time.
Maintain current knowledge of applicable healthcare, Medicaid, privacy, records management, audit, and regulatory requirements relevant to the organization's Mobility and Personal Care Services businesses.
Perform other duties as assigned.

Benefits

Medical, Dental, and Vision insurance
Employer Paid Basic Life Insurance and AD&D
Voluntary Life Insurance (Employee/Spouse/Child)
Health Care and Dependent Care Flexible Spending Accounts
Pre-Tax and Post --Tax Commuter and Parking Benefits
401(k) Retirement Savings Plan with Company Match
Paid Time Off
Paid Parental Leave
Short-Term and Long-Term Disability
Tuition Reimbursement
Employee Discounts (retail, hotel, food, restaurants, car rental and much more!)