Overview

Reports To

Corporate Compliance Officer

This indicates the position functions within the organization's compliance structure and supports enterprise-wide compliance initiatives, audits, investigations, and regulatory monitoring.

Supervisory Responsibilities

None

The position does not directly supervise staff but serves as a subject matter expert and advisor to leadership, providers, and employees.

Coordinates With

All departments, management, providers, and employees throughout the organization.
Clinical and administrative staff across various locations and departments.

Required Education

Bachelor's degree in nursing (BSN).
Active North Carolina Registered Nurse (RN) license.

Required Experience

One of the following:

3-5 years of progressive nursing management experience, or
10+ years of experience in a similar clinical compliance, quality, utilization management, or regulatory role.

Preferred Knowledge

Medicare and Medicaid coverage guidelines.
Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
Healthcare reimbursement practices.
CPT coding and medical coding principles.

Technical Skills

Proficiency with Microsoft Word, Microsoft Excel and EPIC
Office automation and personal computer proficiency.
Email and reporting applications.

Additional Skills & Competencies

Regulatory Knowledge

Working knowledge of HIPAA privacy and security requirements.
Understanding healthcare compliance standards and regulatory expectations.

Communication & Collaboration

Strong verbal and written communication skills are important.
Ability to work closely with multiple departments across the organization and non-FHC clinics such as PMC, PSC, CEA, etc.
Commitment to customer service and fostering positive team relationships.
Ability to educate, influence, and collaborate with clinical and administrative staff.

Analytical Skills

Analytical and statistical problem-solving abilities.
Experience reviewing data, identifying trends, and evaluating compliance risks.
Ability to interpret findings and make practical recommendations.

Problem Solving

Ability to identify operational or compliance issues.
Demonstrated skills in developing creative, effective solutions.
Sound judgment and critical thinking abilities.

Organizational Skills

Strong attention to detail.
Ability to prioritize multiple projects and responsibilities.
Ability to meet deadlines and manage time effectively.

Policy Development & Compliance Program Support

Assist in developing, updating, and maintaining compliance with policies and procedures.
Support implementation and ongoing monitoring of the organization's corporate compliance plan.
Evaluate audit processes and compliance goals and recommend improvements when needed.
Apply structured problem-solving methods to address compliance and operational issues.

Auditing, Monitoring & Investigations

Plan and perform financial, operational, and compliance audits.
Analyze data, evaluate findings, and communicate audit results objectively and impartially.
Monitor medical necessity, clinical documentation, coding, and billing practices.
Conduct inpatient and outpatient chart reviews.
Participate in compliance monitoring activities and internal audits.
Assist with investigations involving suspected non-compliance and support of corrective action implementation.
Maintain confidentiality throughout audit and investigative processes.

Reporting & Risk Management

Prepare reports related to audits, monitoring activities, investigations, and regulatory requirements.
Provide information that supports management of decision-making, risk reduction, and operational effectiveness.
Document audit testing, findings, recommendations, and supporting work papers thoroughly.
Maintain accurate records and compliance documentation.

Education & Training

Develop educational materials related to compliance, documentation, coding, and regulatory requirements.
Provide guidance to employees, leadership, and medical staff on compliance-related matters.
Support organization-wide training regarding ethical conduct, legal requirements, and regulatory standards.
Promote a culture of compliance and accountability.

Professional Skills

Strong analytical, critical thinking, and problem-solving abilities.
Ability to identify compliance risks and develop practical corrective actions.
Attention to detail and accuracy in audit documentation.
Effective verbal and written communication skills.
Sound judgment and ability to provide unbiased evaluations.
Strong organizational skills and ability to manage multiple deadlines.