Compliance Specialist

Under the general supervision of the Vice President of Compliance & Privacy Officer, the Compliance Specialist is responsible for conducting investigations and audits related to fraud, waste, and abuse within the DWIHN provider network. This role includes performing targeted reviews, gathering and analyzing information, and applying relevant regulations, policies, and internal controls to assess compliance. The Compliance Specialist also supports the implementation of policies, procedures, and control measures to ensure that DWIHN and its providers adhere to applicable regulatory and ethical standards.

Principal Duties and Responsibilities:

• Conduct investigations related to suspected fraud, waste, and abuse.
• Collect, review, and analyze documents, data, claims, medical records, and evidence.
• Perform interviews with staff, providers, witnesses, or relevant parties.
• Conduct audits and reviews to detect potential fraud, waste, and abuse.
• Maintain knowledge of state, federal, and internal regulations, policies, and billing requirements.
• Maintain accurate records of investigations and prepare comprehensive reports.
• Recommend and help implement corrective action plans and training.
• Collaborate with internal departments and external enforcement authorities.
• Assist in training staff and providers on fraud and abuse prevention.
• Stay current with regulatory changes and enforcement trends.
• Maintain confidentiality and adhere to privacy and data security requirements.

Requirements and Qualifications:

• Bachelor’s degree in Criminal Justice, Business Administration, Public Administration, Accounting / Finance, Healthcare Administration, Human Resources, Health Information Management, Law / Legal Studies, or Social Services / Social Work.
• One year of professional investigation experience plus at least two years in a healthcare setting.
• Valid State of Michigan Driver’s License.
• Certification as a Healthcare Compliance Officer (CHC) preferred.

Skills:

• Knowledge of healthcare fraud and abuse laws and governmental compliance regulations.
• Strong analytical, investigative, organizational, and communication skills.
• Ability to work collaboratively with diverse populations.

Work Conditions:

• Hybrid role with office-based work and travel within Wayne County and Michigan.

Compliance with COVID-19 vaccination requirements per employer policy.