Compliance Specialist

Compliance Specialist Position Overview Location: Hybrid onsite Tuesday, Wednesday, and Thursday The Compliance Specialist is responsible for supporting quality management and credentialing initiatives to ensure compliance with regulatory, accreditation, and legislative requirements. This role will focus on program evaluation, audit support, reporting, credentialing analysis, and identifying opportunities for process improvement. The ideal candidate is analytical, detail-oriented, and able to work independently. Key Responsibilities Collaborate with internal and external stakeholders to improve processes and ensure compliance. Analyze data and existing databases for accuracy, reliability, and reporting purposes. Develop specifications for business intelligence reports, audits, and ad hoc reporting. Research quality issues identified through regulatory agencies, executive inquiries, fraud investigations, and other referral sources. Develop and maintain tools used for audits and reporting. Analyze audit findings, identify credentialing issues, and recommend corrective actions. Support Credentialing Services through database coordination, report generation, data quality review, and process evaluation. Review potential credentialing non-compliance and discrimination cases. Conduct gap analyses between regulatory requirements and company policies. Maintain desk procedures, process documentation, and program materials. Prepare reports, findings, and recommendations for leadership. Qualifications Bachelors degree required RN license, Masters degree in Public Health, clinical license, or equivalent experience preferred Minimum of five (5) years of experience in a managed care environment Strong knowledge of NCQA, CMS, and state and federal healthcare regulations Experience with credentialing, audits, compliance, and quality management initiatives preferred Strong analytical, organizational, written, and communication skills Ability to work independently, manage priorities, and collaborate across teams