Compliance Specialist

Compliance Specialist

The Compliance Specialist supports the organization's Medicare Advantage program and SMAC contract by ensuring compliance with all applicable federal and state regulations, including CMS requirements. This position reports to the Director of Compliance and is responsible for monitoring regulatory updates, conducting compliance reviews, analyzing policies and procedures, supporting internal and external audits, and assisting in the development and implementation of corrective action plans. The Compliance Specialist collaborates with internal departments and external partners to promote adherence to contractual and regulatory obligations, minimize compliance risks, and support a culture of compliance across the organization. Position is onsite Monday-Friday.

Essential Duties and Responsibilities

• Monitor CMS regulatory updates and communicate impacts internally
• Support internal and external audits
• Prepare compliance reports and committee materials
• Develop compliance training for internal teams
• Conduct compliance audits and monitoring activities across enrollment, claims, UM, and case management
• Identify trends, gaps, and risks through ongoing operational monitoring and escalate findings
• Support development of corrective action plans tied to audit findings

Qualifications and Education

• Bachelor's or master's degree in healthcare administration.

• Minimum of 2–4 years of experience in healthcare compliance, preferably with Medicare Advantage or Medicaid programs

• Knowledge of CMS regulations, Medicare Advantage requirements, SMAC contracts, and compliance best practices.

• Experience working with CTM (Complaint Tracking Module), HPMS (Health Plan Management System), and other compliance monitoring tools preferred.

• Strong analytical, research, and problem-solving skills.

• Excellent verbal and written communication skills, including ability to prepare reports and deliver presentations.

• Detail-oriented with strong organizational and time-management skills.

• Ability to collaborate effectively across multiple departments and manage multiple projects simultaneously.

Knowledge and Skills

• In-depth understanding of healthcare regulations and compliance standards related to Medicare Advantage and Medicaid programs.

• Familiarity with CMS reporting requirements, including HPMS and CTM processes.

• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook).

• Ability to analyze complex regulatory information and translate it into actionable business guidance.

• Strong interpersonal skills to build relationships with internal teams and external regulatory bodies.

• Ability to maintain confidentiality and handle sensitive information with discretion.

• Project management skills to support audits, policy development, and committee activities

Working Conditions

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The noise level in the work environment is usually moderate.

• Fast-paced office environment.

• Highly regulated environment.

• Interacts with patients, family members, staff, visitors, government agencies, etc, under a variety conditions and circumstances.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or listen. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.