Healthcare Compliance Investigator

Healthcare Compliance Investigator

Work Location: Remote – Must reside and be licensed in the State of Ohio

Pay Range: $48,000.00 - $53,000.00 annually

Position Summary

The Healthcare Compliance Investigator I is responsible for investigating incidents involving Medicaid recipients and/or providers to ensure the health, safety, and welfare of individuals receiving services. This role conducts thorough investigations, coordinates with internal and external stakeholders, and ensures compliance with Ohio Medicaid and HCBS regulations.

Essential Duties & Responsibilities

• Conducts investigations of reported incidents involving Medicaid recipients and providers to ensure health and welfare standards are met.
• Reviews and analyzes documentation including clinical records, incident reports, billing records, and other relevant materials.
• Performs interviews with recipients, providers, witnesses, and other involved parties using effective interviewing and active-listening techniques.
• Accurately documents all investigative activities, findings, and conclusions in the incident reporting system.
• Identifies rule violations, contributing factors, and potential risks; develops clear, well-supported investigation summary reports.
• Educates Medicaid providers on applicable rules, responsibilities, and best practices related to service delivery.
• Coordinates and refers cases to external entities as appropriate, including:
• Law enforcement
• County children services
• Adult Protective Services
• County Boards of Developmental Disabilities
• Other oversight or regulatory agencies
• Gathers information and prepares referrals to the Ohio Department of Medicaid for suspected or egregious provider misconduct.
• Maintains professionalism and confidentiality while working independently in a remote environment.
• Performs other duties as assigned to support departmental needs.

Required Knowledge, Skills, & Abilities

• Strong critical-thinking and analytical skills with the ability to synthesize complex information.
• Excellent organizational skills with the ability to manage multiple investigations concurrently.
• Strong verbal and written communication skills, including professional report writing.
• Effective interviewing and active-listening abilities.
• Ability to work independently and collaboratively within a team environment.
• Strong decision-making skills with a high level of accuracy and attention to detail.
• Demonstrated professionalism and ability to work respectfully with individuals from diverse backgrounds.
• Proficiency with Microsoft Word, Excel, Outlook, and internet-based systems.

Minimum Qualifications

Education / Licensure (One Required)

• Licensed Registered Nurse (RN) – Ohio
• Licensed Social Worker (LSW or LISW) – Ohio
• Licensed Professional Counselor (LPC or LPCC) – Ohio

Experience

• Minimum of 1 year of paid experience in Home and Community-Based Services (HCBS), including one or more of the following:
• Incident investigation
• Ensuring individual health and welfare
• Quality assurance or clinical risk management
• Mental health or addiction services
• Interfacing with law enforcement, nursing homes, children services, adult protective services, or the Ohio Department of Developmental Disabilities
• Providing waiver services (e.g., home health or other HCBS services)

Work Environment

• Fully remote position within Ohio
• Occasional travel (1 to 2 times per year) within the Central Ohio area may be required for training
• May involve exposure to sensitive or emotionally challenging information
• Standard business hours with flexibility based on investigative needs

Benefits (Through SSO)

SSO offers a competitive benefits package that supports your health, financial well-being, and long-term growth, including:

• Medical, dental, and vision insurance
• 401(k) with discretionary employer match
• Paid time off and holidays
• Flexible spending accounts
• Additional employee perks