Senior Compliance Specialist – Payment Integrity

Das ist der Job

Experience within Payment Integrity, health plan, payer‑side, or managed care operations #J-18808-Ljbffr

Darum lohnt es sich

Serve as the primary compliance liaison for Payment Integrity and Payment Operations, providing strategic guidance on regulatory and operational compliance matters.

Interpret, analyze, and operationalize applicable regulatory requirements, including the No Surprises Act (NSA), Fraud, Waste & Abuse (FWA) laws, CMS requirements, and state Department of Insurance (DOI) regulations impacting payment and billing practices.

Provide compliance oversight and guidance related to payment workflows, reimbursement methodologies, claims administration processes, and product development initiatives. Partner cross‑functionally with operational leaders to identify, assess, and mitigate financial and regulatory compliance risks associated with payment and claims functions.

Monitor and evaluate emerging regulatory developments, enforcement trends, and industry guidance to determine operational impact and support implementation of required changes. Support the development, review, implementation, and maintenance of financial and payment‑related policies, procedures, and standard operating procedures (SOPs).

Participate in high‑risk initiatives, system implementations, process enhancements, and product changes to ensure compliance considerations are appropriately addressed. Assist with incident response activities involving payment disputes, FWA‑related escalations, regulatory inquiries, and other compliance‑related matters.

Support internal audits, external audits, client audits, and regulatory examinations by coordinating documentation, responding to inquiries, and ensuring audit readiness.

Collaborate with Corporate Compliance and cross‑functional stakeholders on issue intake, triage, investigation support, tracking, corrective action planning, and resolution activities.

Develop and deliver training, education, and compliance guidance to internal stakeholders regarding applicable regulatory requirements, policies, and operational expectations. Maintain accurate and organized documentation supporting compliance oversight activities, monitoring efforts, investigations, and audit preparedness.

Requirements Bachelor’s degree required; concentration in Healthcare Administration, Finance, Business Administration, or a related field preferred 5+ years of progressive experience in healthcare compliance, payment integrity, regulatory compliance, or related healthcare operations Certified Professional Coder (CPC) credential or equivalent coding certification Demonstrated knowledge and experience with claims processing operations and/or payment integrity programs Demonstrated knowledge of healthcare billing, coding, and reimbursement regulations Demonstrated experience with Fraud, Waste & Abuse (FWA) compliance frameworks and investigative processes A plus if you have… Experience supporting No Surprises Act (NSA) implementation, oversight, and compliance activities.