Under the general supervision of the Compliance Officer, the Compliance Specialist assists with the planning, development and implementation of compliance activities which includes performing regular audits, conducting investigations, performing research, and implementing DWIHN policies and design control systems to ensure that DWIHN complies with regulatory and ethical standards.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Assists with the planning, development and implementation of compliance activities for DWIHN.
• Performs regular audits and internal reviews.
• Conducts investigations.
• Performs research.
• Implements DWIHN policies and design control systems.
• Educates DWIHN employees about compliance related matters including billing and documentation requirements; vendor relationships; DWIHN member quality and safety; and policies and regulations of the Office of Inspector General (OIG)/NCQA.
• Performs investigations of alleged compliance incidents/violations.
• Develops corrective action plans for the resolution of problematic issues.
• Tracks, monitors, and provides reports for all investigation outcomes.
• Researches, audits and/or analyzes complex data.
• Assists with the development, maintenance, and revision of policies, procedures and practices for DWIHN to prevent illegal, unethical, or improper conduct.
• Conducts regular on-going review and analysis of all relevant contractual provisions and state and federal statutes and regulations.
• Develops policies and procedures to conform to relevant state, federal, and/or industry standards and requirements and coordinates efforts with appropriate departmental staff to ensure implementation.
• Researches questions from staff regarding regulatory compliance.
• Responds to external requests for information.,

• Identifies compliance issues that require remediation.
• Files compliance reports with DWIHN for regulatory agencies.
• Verifies oversight and monitoring activities.
• Consults with legal counsel regarding compliance issues.
• Researches emerging compliance issues.
• Trains employees on compliance topics.
• Assists external auditors with internal and external audits.
• Reports to management and the Board of Directors on DWIHN's compliance program.
• Determines compliance metrics and establishes a system for tracking these metrics.
• Maintains up to date written documentation related to DWIHN policies and procedures.
• Creates a compliance resource library for staff members.
• Reports compliance violations
• Regularly assesses the efficiency of control systems and recommends improvements.
• Reviews and evaluates DWIHN's procedures and reports to identify hidden risks or common issues.
• Coordinates with DWIHN staff to review all departmental compliance policies.
• Performs periodic audits on company procedures and processes.
• Leads employee training sessions on legal and compliance issues.
• Assists with NCQA certification and compliance.
• Assists with Quality Management and Quality Improvement functions.
• Performs related duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES (KSA'S):

• Knowledge of health care fraud and abuse laws, including the False Claims Act, Stark Laws, and the Anti-Kickback Statute, including the associated penalties.
• Knowledge of health care law, regulations and standards.
• Knowledge of governmental compliance regulations.
• Knowledge of DWIHN policies, procedures and practices.
• Knowledge of the DWIHN provider network and community resources.
• Knowledge of the Michigan Mental Health Code.
• Knowledge of MDHHS policies, rules, regulations and procedures.
• Knowledge of Federal policies, rules, regulations and procedures as it relates to DWIHN.
• Knowledge of NCQA requirements and the accreditation process.
• Knowledge of contracting policies and procedures.
• Knowledge of Quality Management and Improvement principles and practices.
• Knowledge of HIPPA Compliance.
• Corrective Action skills.
• Assessment skills.
• Organizational skills.
• Accuracy skills.
• Analytical skills.
• Time Management skills.
• Report writing skills.
• Logical skills.
• Reasoning skills.
• Problem Solving skills
• Decision Making skills.
• Interpersonal skills.
• Computer skills.
• Teamwork Skills
• Ability to communicate orally.
• Ability to communicate in writing.
• Ability to work effectively with others.
• Ability to act ethically and with confidentiality.
• Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population.
• Judgement/Reasoning ability.

REQUIRED EDUCATION:

A Bachelor's degree in Business Administration, Healthcare Administration, Public Administration, the Human Services, the Social Services, or a related field or a Juris Doctorate.

REQUIRED EXPERIENCE:

Three (3) years of full-time paid professional experience performing compliance duties and responsibilities including at least one (1) year of experience working in a mental health or behavioral health setting.

REQUIRED LICENSE(S).

A valid State of Michigan Driver's License with a safe and acceptable driving record.

WORKING CONDITIONS:

Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. This position can work remotely with supervisory approval. Currently this position is a hybrid position.

This description is not intended to be a complete statement of job content, rather to act as a general description of the essential functions performed. Management retains the discretion to add or change the position at any time.

Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process.

The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer