Senior Compliance Specialist – Payment Integrity

• 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. Experience within Payment Integrity, health plan, payer‑side, or managed care operations