SENIOR HEALTHCARE COMPLIANCE REVIEWER

Healthcare Management Solutions LLC•Fairmont, WV

12d•Remote

About The Position

This position supports federal oversight activities designed to ensure insurance organizations participating in the Health Insurance Marketplace comply with applicable regulatory and operational requirements. Compliance Reviewers analyze policies, procedures, and supporting documentation; assess adherence to federal standards; identify potential compliance concerns; and document review results. This senior-level role requires strong analytical skills, attention to detail, professional communication, and the ability to manage competing priorities while handling sensitive information in a confidential manner.

Requirements

Experience conducting compliance reviews, audits, monitoring activities, or quality assurance assessments.
Knowledge of healthcare, health insurance, regulatory compliance, or federally funded programs.
Ability to interpret and apply regulations, policies, procedures, and technical guidance.
Strong analytical and critical thinking skills with the ability to identify discrepancies and compliance risks.
Strong written communication skills, including experience documenting findings and preparing reports.
Ability to organize, prioritize, and manage multiple assignments while meeting deadlines.
Proficiency in Microsoft Office Suite, particularly Excel, Word, Outlook, and Teams.
Ability to handle sensitive and confidential information with discretion and professionalism.
Strong interpersonal skills and the ability to collaborate effectively in a remote team environment.
Bachelor's Degree (Healthcare industry related is preferred) or an equivalent combination of relevant education and work experience
Project Management Professional (PMP) certification is required.

Nice To Haves

Familiarity with Health Insurance Marketplace operations, health plan oversight, or healthcare regulations preferred.
Project management experience, including coordinating work across multiple priorities, tracking deliverables, supporting timelines, and communicating status updates, is preferred.
Experience supporting federal contracts, audit activities, compliance reviews, or similar project-based work is preferred.
Ability to take ownership of assigned workstreams, exercise sound judgment, and support consistent execution of project requirements.
Certified internal/external auditor (CIA) a plus.
Insurance Regulatory Examiners Society (IRES) professional designation (MCM, AIE) is a plus.

Responsibilities

Conduct detailed reviews of policies, procedures, records, and supporting documentation to assess compliance with federal requirements.
Analyze operational processes and identify potential compliance risks, deficiencies, or areas requiring corrective action.
Compare evidence and documentation against established review protocols, regulations, and guidance.
Document review results, observations, and findings in accordance with project standards and reporting requirements.
Prepare written summaries, reports, and recommendations based on review results.
Communicate professionally with project staff and stakeholders regarding review activities and requests for information.
Provide guidance and support to reviewers on complex compliance issues, review methodologies, and documentation standards.
Assist with the development, refinement, and implementation of review processes, tools, and procedures.
Support project planning efforts by providing status updates, workload estimates, and recommendations related to assigned review activities.
Ensure the secure handling of sensitive and confidential information in compliance with HIPAA and company policies.
Meet established productivity, quality, and timeliness expectations.