Compliance Examiner & Auditor - Integrity & Compliance Program - Full Time

Position Summary The Healthcare Compliance Analyst & Examiner is responsible for ensuring organizational adherence to federal, state, and local healthcare regulations, as well as internal policies and procedures for the audit program. This role conducts audits, risk assessments, and data analysis to identify compliance vulnerabilities, develops and implements corrective action plans, and provides training and guidance to staff. Working with the VP, Chief Compliance officer will be responsible for the daily management of auditors; ensuring ongoing training, workplan completion and policy adherence. The Analyst collaborates with cross-functional teams—including legal, clinical, IT, and administrative departments—to foster a culture of compliance, accountability, and continuous improvement.

Key Responsibilities

Regulatory Compliance & Risk Management

• Monitor and interpret changes in healthcare laws and regulations (e.g., CMS, Stark Law, Anti-Kickback Statute, ACA, state-specific requirements).
• Develop, implement, and maintain compliance policies, procedures, for the audit program.
• Conduct regular audits and reviews of medical records, billing, coding, provider activity, and departmental processes to ensure compliance with regulatory standards.
• Perform risk assessments to identify areas of vulnerability and recommend corrective actions.
• Investigate compliance billing-related incidents and ensuring proper documentation and reporting to authorities.
• Responsible for the daily management of compliance auditors
• Support responses to external audits and inspections.

Data Analysis & Reporting

• Analyze data to detect patterns, trends, and anomalies that may indicate compliance issues.
• Prepare comprehensive reports on compliance activities, findings, and outcomes for management and regulatory bodies.
• Maintain documentation of all compliance activities, methodologies, results, and corrective actions.

Training & Education

• Develop and deliver compliance training programs for employees at all levels.
• Create educational materials and resources to support ongoing compliance education.
• Stay current with industry best practices, regulatory updates, and emerging technologies (e.g., AI, data analytics platforms).

Collaboration & Communication

• Work closely with Compliance Officers, legal counsel, IT, clinical teams, and external partners.
• Present findings and recommendations to senior management, committees, and other stakeholders.
• Foster a culture of transparency, ethical conduct, and continuous improvement.

Continuous Improvement & Technology

• Integrate lessons learned from internal and external compliance issues into training and program development.
• Leverage data analytics tools (e.g., Power BI, Tableau) and EHR systems (e.g., EPIC) to enhance compliance operations.
• Monitor and test the effectiveness of compliance programs and technologies, ensuring alignment with organizational values and regulatory requirements.

Qualifications

• Certification in healthcare compliance (e.g., CHC, CHCP, CHRC, CPC, CPMA, CCS, RHIA, RHIT, LPN); Certified Fraud Examiner preferred.
• Minimum 2–5 years of experience in healthcare compliance, auditing, or clinical management.
• Strong knowledge of medical terminology, anatomy, coding guidelines (CPT, ICD-10/11, HCPCS), payer requirements, and reimbursement processes.
• Experience with regulatory reporting, documentation, and compliance monitoring systems.
• Advanced proficiency in Microsoft Office Suite; experience with data analytics platforms and EHR systems preferred.
• Excellent analytical, organizational, and problem-solving skills.
• Outstanding written and verbal communication skills; ability to present complex information clearly.
• Ability to work independently and collaboratively in a team environment.
• High level of discretion and confidentiality with sensitive information.

Essential Functions

• Conduct concurrent, prospective, and retrospective audits of medical records, and billing, provider activity.
• Coordinate compliance-related audits, including governmental audits and appeals.
• Communicate audit results and corrective actions to all relevant parties.
• Research legislation, standards, and policies; provide analysis and recommendations.
• Develop and manage audit workplans and strategies.
• Maintain documentation and support training initiatives.
• Coordinate with internal/external auditors and legal counsel.
• Present audit findings to management and committees.
• Maintain professional and technical job knowledge through ongoing education and participation in professional organizations.
• Create and maintain KPI dashboards and compliance workplans.
• Direct responsibility for completion of compliance audit workplan items.

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