Compliance Officer - Behavioral Health

Clinical Compliance Officer – Behavioral Health Organization: Upward Community Status: Part-Time or Full-Time, depending on clinical responsibilities Reports To: Executive Director / Clinical Director Position Summary Upward Community is seeking an experienced Clinical Compliance Officer to oversee clinical, regulatory, documentation, and quality compliance across our behavioral health services, including both Illinois Medicaid/BHC services and commercial/PPO services. The Clinical Compliance Officer will help ensure that clinical programs, documentation, staff practices, policies, procedures, and EHR workflows meet applicable Illinois Medicaid, commercial insurance, privacy, and behavioral health requirements. This individual will serve as an internal compliance resource for leadership, supervisors, clinicians, billing staff, and administrative staff. The position will take the lead in ongoing compliance monitoring, internal auditing, staff education, corrective action, quality improvement, and readiness for payer, state, accreditation, and other regulatory reviews. The role may be combined with clinical supervision or a clinical caseload depending on the candidate's qualifications and availability. Key ResponsibilitiesRegulatory Compliance & Survey Readiness Maintain ongoing compliance with applicable Illinois HFS requirements for Behavioral Health Clinics, including relevant provisions of Rule 140 and the Community-Based Behavioral Services Provider Handbook. Monitor applicable Medicaid, commercial insurance, privacy, and behavioral health regulatory requirements. Maintain organizational readiness for HFS, Medicaid MCO, commercial payer, accreditation, and other regulatory audits and reviews. Serve as a primary internal resource during regulatory and payer audits, surveys, and compliance reviews. Coordinate preparation of clinical and compliance documentation requested during audits or reviews. Develop and monitor corrective action plans when deficiencies or compliance concerns are identified. Work with leadership, legal counsel, billing specialists, and outside regulatory consultants when interpretation of requirements is needed. Clinical Documentation & Chart Auditing Conduct routine compliance reviews and spot audits of Medicaid and commercial/PPO clinical records. Review documentation for medical necessity, appropriate service documentation, treatment planning, diagnoses, signatures, credentials, required timelines, and other applicable clinical and payer requirements. Review Medicaid documentation for compliance with applicable service definitions, staff qualifications, IM+CANS requirements, LPHA review, and HFS requirements. Review commercial/PPO documentation for consistency with applicable payer requirements, coding standards, medical necessity, and clinical documentation requirements. Identify documentation trends and recurring compliance concerns across clinicians, supervisors, programs, and payer types. Establish a regular internal chart-audit process and maintain records of findings, follow-up, and corrective action. Work with clinical supervisors when documentation deficiencies or patterns require staff remediation. Billing & Payer Compliance Oversight Work collaboratively with billing staff to identify potential compliance concerns involving Medicaid, Medicaid MCOs, and commercial/PPO payers. Periodically review the relationship between services documented and services billed to identify potential coding or documentation concerns. Monitor patterns involving duplicate or incompatible services, incorrect codes, provider eligibility, credentialing, or other potential billing compliance concerns. Review payer audit findings, recoupment requests, or recurring denials when they may indicate a larger compliance issue. Assist leadership in developing corrective processes when systemic billing or documentation concerns are identified. Help ensure services are provided and billed by appropriately licensed, credentialed, and paneled professionals when required. Collaborate with the billing team while maintaining a clear distinction between compliance oversight and routine billing functions. EHR & Clinical Workflow Compliance Work with clinical leadership and EHR support staff to ensure clinical workflows, forms, templates, documentation requirements, and approval processes support regulatory and payer compliance. Identify EHR configuration or workflow issues that may create compliance risk and assist in developing corrective solutions. Review the implementation of new documentation forms, service types, programs, and clinical workflows for compliance. Help ensure EHR processes appropriately support requirements such as IM+CANS, LPHA review, signatures, treatment plans, service documentation, and required timelines. Recommend modifications to EHR forms, templates, and workflows when needed to improve compliance and documentation quality. Maintain and periodically review clinical compliance policies and procedures covering Medicaid and commercial services. Ensure policies reflect current Illinois HFS, Medicaid, HIPAA/privacy, payer, and other applicable requirements. Work with leadership to develop or revise policies when regulations, payer requirements, programs, or organizational practices change. Maintain organized compliance records needed for audits, surveys, and payer reviews. Assist with development and implementation of corrective action plans when policies or procedures are not being followed. Staff Training & Accountability Identify required annual and recurring compliance training for clinical and applicable administrative staff. Maintain a compliance training calendar and monitor completion of required trainings. Coordinate training related to regulatory changes, payer requirements, documentation standards, and identified compliance concerns. Follow up with staff and supervisors when required training, documentation, signatures, credentials, licenses, or other compliance requirements are outstanding. Provide or coordinate targeted education and remediation when audits identify recurring issues. Work with supervisors to ensure corrective actions are completed and sustained. Credentialing & Staff Compliance Monitor clinical licenses, credentials, required qualifications, and other documentation necessary for staff to provide Medicaid and commercial insurance services. Work with leadership and credentialing staff to ensure providers are appropriately credentialed and paneled for the services they provide. Maintain systems for tracking license expirations, renewals, certifications, training requirements, and compliance documentation. Review staff qualifications when new programs or Medicaid services are developed or implemented. Help identify situations in which provider credentials, licensure, or payer enrollment could affect the organization’s ability to provide or bill for services. Quality Assurance & Performance Improvement Lead or actively participate in Upward Community’s Quality Assurance and Quality Improvement activities and applicable committees. Monitor quality and compliance trends across programs and identify opportunities for improvement. Assist leadership in evaluating whether clinical programs and services are meeting regulatory, payer, documentation, and organizational quality standards. Conduct periodic compliance risk assessments across Medicaid and commercial services. Identify areas of potential regulatory, documentation, billing, privacy, or clinical risk. Track identified deficiencies, corrective actions, and recurring trends to ensure issues are addressed and improvements are sustained. Recommend operational improvements designed to reduce compliance risk and strengthen quality. Prepare periodic compliance and quality reports for leadership summarizing audit findings, documentation trends, training compliance, outstanding corrective actions, and significant areas of organizational risk. Qualifications Master's degree in Social Work, Counseling, Psychology, or a related behavioral health field strongly preferred. Current Illinois clinical license required such as LCSW, LCPC, LMFT, or Licensed Clinical Psychologist. LPHA qualification strongly preferred. Experience working in an Illinois behavioral health setting. Experience with Illinois Medicaid behavioral health requirements. Knowledge of commercial/PPO behavioral health documentation and payer requirements. Working knowledge of Illinois HFS Behavioral Health Clinic requirements, Rule 140, Medicaid community-based behavioral health services, and IM+CANS preferred. Experience conducting clinical documentation audits or compliance reviews. Experience preparing for regulatory, Medicaid, MCO, commercial payer, or accreditation audits strongly preferred. Understanding of HIPAA, privacy, clinical documentation, medical necessity, coding, and behavioral health compliance requirements. Strong organizational, analytical, problem-solving, and follow-through skills. Ability to interpret regulatory and payer requirements and translate them into practical procedures for staff. Ability to work collaboratively with clinical leadership, supervisors, clinicians, billing staff, administrative leadership, EHR support, and outside consultants. Preferred Experience Previous compliance, quality assurance, clinical supervision, or leadership experience within an Illinois BHC, CMHC, or behavioral health organization. Experience with both Medicaid and commercial behavioral health insurance. Experience with Medicaid MCO and commercial payer credentialing. Experience developing and maintaining clinical policies and procedures. Experience creating, implementing, and monitoring corrective action plans. Familiarity with behavioral health coding and billing requirements. Experience training and supporting behavioral health clinicians. Experience working with behavioral health EHR systems and developing or improving clinical documentation workflows. #J-18808-Ljbffr Upward Community Services