Compliance Review Specialist

The Compliance Review Specialist supports Heartshare's regulatory and billing compliance efforts by conducting audits, monitoring corrective measures, ensuring documentation accuracy, and supporting adherence to Federal, State, City, and Agency regulatory standards. The role collaborates with program staff, leadership, and external oversight agencies to promote compliance, reduce risk, and improve operational effectiveness.

Responsibilities include:

• Conducting manual and electronic record reviews for compliance with policies and regulatory standards (Medicaid, OPWDD, DOH, OMH, ACS).
• Scheduling and completing clinic and Children’s Community Residences (CCR) case record reviews to verify accuracy, completeness, and alignment with treatment plans.
• Monitoring documentation discrepancies, including duplications and potential fraud.
• Generating audit reports and tracking corrective actions.
• Participating in state and federal audits as support and liaison.
• Conducting OMIG billing reviews to ensure claims meet regulatory requirements and timely billing.
• Identifying discrepancies and coordinating follow-up actions including self-disclosures.
• Completing monthly self-disclosures for voided claims alongside the Billing Compliance Officer.
• Analyzing compliance reports and recommending improvements to reduce risk.
• Providing staff training on compliance standards and best practices.
• Supporting programs in maintaining compliance with applicable rules, regulations, and policies.

Qualifications:

• Bachelor’s degree in Health Administration, Social Work, Public Health, or related field preferred.
• 2-5 years of experience in case review, QA/Compliance, or similar roles.
• Knowledge of Medicaid, ACS, OMIG, OMH, OPWDD, and DOH regulations.
• Experience with billing and EHR systems (e.g., Precision Care, Asara, Millin) is a plus.
• Strong attention to detail, analytical skills, organizational abilities, and excellent communication skills.
• Ability to work collaboratively across teams and programs.

Benefits include:

• Paid vacation, sick, personal days, and holidays.
• 403(B) retirement plans with employer contribution.
• Health, dental, vision, and life insurance.
• Employee Assistance Program (EAP).
• Flexible spending accounts.
• Tuition assistance and professional development opportunities.
• Employee discounts and appreciation programs.

HeartShare is an equal opportunity employer committed to empowering New Yorkers with intellectual and developmental disabilities.