Compliance Specialist

Compliance Specialist

St. Joseph's Villa is seeking a detail-oriented and organized Compliance Specialist to support agency-wide regulatory compliance, quality assurance, documentation monitoring, insurance authorization tracking, provider credentialing, reporting, and quality improvement activities.

Under the direction of the Compliance Manager, the Compliance Specialist conducts audits, monitors documentation and regulatory requirements, tracks corrective actions, supports insurance and billing processes, and maintains accurate compliance records. This position works collaboratively with program leadership, Finance, Admissions, Human Resources, and other departments to identify compliance concerns, resolve discrepancies, and support adherence to applicable regulatory, contractual, payer, and agency requirements.

The Compliance Specialist assists with monitoring requirements established by the Virginia Department of Behavioral Health and Developmental Services (DBHDS) and the Virginia Department of Education (VDOE), including preparation for licensing visits, regulatory reviews, insurance audits, and other monitoring activities.

The successful candidate will demonstrate strong analytical skills, attention to detail, organizational ability, and a commitment to confidentiality, professional ethics, and continuous improvement. All responsibilities must align with St. Joseph's Villa's mission, values, policies, and guiding principles.

Responsibilities

Compliance Monitoring and Auditing

• Conduct routine and random audits of client records, program documentation, and related records to assess compliance with regulatory, contractual, payer, and agency requirements.
• Review documentation for completeness, accuracy, required signatures, authorizations, and other applicable standards.
• Document audit findings, communicate identified deficiencies, and track corrective actions through resolution.
• Conduct follow-up audits to verify that deficiencies have been corrected and compliance requirements are met.
• Assist with preparation for licensing visits, regulatory reviews, insurance audits, payer reviews, and other monitoring activities.
• Support the Compliance Manager in monitoring DBHDS and VDOE requirements through record collection, data tracking, research, and follow-up.
• Identify recurring compliance issues, trends, and areas of risk and report findings to the Compliance Manager.

Insurance and Authorization Monitoring

• Collaborate with program teams and Finance to obtain information needed to resolve billing and claims issues.
• Research unpaid, denied, rejected, or unsubmitted insurance claims and coordinate follow-up as needed.
• Reconcile insurance authorizations, services delivered, and billing information to identify discrepancies.
• Track authorization requirements and communicate outstanding issues to appropriate departments.

Credentialing and Recredentialing

• Coordinate and track agency, program, and provider credentialing and recredentialing activities.
• Collect, review, and organize required credentialing documentation.
• Monitor applications, effective dates, expiration dates, outstanding requirements, and payer responses.
• Assist with credentialing submissions to public and private insurance entities.
• Maintain accurate credentialing records and monitor renewal deadlines to support uninterrupted provider participation.
• Support credentialing requirements for new programs, services, and providers.

Reporting and Quality Improvement

• Collect, verify, organize, and maintain compliance-related data and tracking systems.
• Prepare routine reports on audit results, documentation deficiencies, insurance authorizations, credentialing, claims-related issues, and corrective actions.
• Reconcile records and reports to verify accuracy and identify discrepancies.
• Track compliance deadlines, renewals, corrective actions, and required submissions.
• Identify trends, process gaps, and opportunities for improvement and communicate recommendations to the Compliance Manager.
• Assist with implementing and monitoring approved quality improvement initiatives.

Regulatory and Policy Support

• Research regulatory, contractual, and payer requirements as assigned.
• Monitor assigned regulatory updates and maintain applicable compliance guidance and resources.
• Support the Compliance Manager in monitoring DBHDS and VDOE requirements and changes in applicable regulations.
• Assist with updating compliance tools, forms, checklists, and procedures following approved changes.
• Gather information to support the development and revision of policies and procedures.
• Assist with implementing approved regulatory, contractual, and agency policy changes.

Training and Departmental Support

• Assist with developing and delivering compliance-related training and educational materials.
• Provide routine guidance to staff on established documentation, authorization, credentialing, and compliance procedures.
• Coordinate requests for missing or incomplete documentation and follow up to support timely completion.
• Collaborate with program leadership, Finance, Admissions, Human Resources, and other departments to address compliance needs.
• Escalate significant, recurring, or unresolved compliance concerns to the Compliance Manager.

Qualifications

• Associate degree in business, healthcare administration, human services, behavioral health, education, or a related field.
• Strong organizational skills and attention to detail, with the ability to manage multiple priorities and deadlines.
• Proficiency with Microsoft Office applications, electronic records systems, databases, and web-based platforms.
• Ability to review documentation, maintain accurate records, identify discrepancies, and communicate findings effectively.
• Ability to handle confidential information with discretion and professionalism.
• Strong written and verbal communication skills and the ability to collaborate across departments.