COMPLIANCE SPECIALIST

Under the general supervision of the Vice President of Compliance & Privacy Officer, the Compliance Specialist is responsible for conducting investigations and audits related to fraud, waste, and abuse within the DWIHN provider network. This role includes performing targeted reviews, gathering and analyzing information, and applying relevant regulations, policies, and internal controls to assess compliance. The Compliance Specialist also supports the implementation of policies, procedures, and control measures to ensure that DWIHN and its providers adhere to applicable regulatory and ethical standards.

PRINCIPAL DUTIES AND RESPONSIBILITIES:**

Conduct FWA Investigations: Manage investigations related to suspected fraud, waste, and abuse within the provider network.

Data Gathering & Analysis: Collect, review, and analyze relevant documents, data, claims, medical records, and other evidence to assess compliance with applicable regulations.

Interviews: Perform interviews with staff, providers, witnesses, or other relevant parties as part of the investigation process.

Compliance Reviews & Audits: Perform targeted audits and reviews to detect patterns indicative of potential FWA.

Research Regulations & Policies: Maintain working knowledge of state, federal, and internal regulations, policies, and billing requirements related to FWA.

Documentation & Case Management: Maintain accurate and thorough records of investigation activities, findings, and outcomes in compliance with applicable policies and regulations.

Reporting: Prepare comprehensive investigation reports and summaries for internal review, external regulators, or enforcement authorities.

Corrective Action Plans: Recommend and/or collaborate with staff and providers to implement corrective action plans and training for identified deficiencies.

Collaboration: Partner with internal departments (Managed Care Operation, Quality, Clinical) and external enforcement authorities (e.g., OIG, Attorney General) as needed.

Education & Prevention: Assist in training staff and providers on FWA prevention, detection, and compliance best practices.

Regulatory Monitoring: Stay current with changes in state and federal regulations and enforcement trends related to FWA.

Privacy & Confidentiality: Maintain confidentiality of sensitive information and adhere to privacy and data security requirements throughout the investigation process.

KNOWLEDGE, SKILLS AND ABILITIES (KSA'S)

Knowledge**

Health care fraud and abuse laws (e.g., False Claims Act, Stark Law, Anti-Kickback Statute) and associated penalties

General health care laws, regulations, and standards

Governmental compliance regulations

DWIHN policies, procedures, and practices

DWIHN provider network and community resources

Michigan Mental Health Code

MDHHS policies, rules, regulations, and procedures

Federal policies, rules, regulations, and procedures as related to DWIHN

NCQA requirements and the accreditation process

Contracting policies and procedures

Quality Management and Improvement principles and practices

HIPAA compliance and privacy standards

Skills

Corrective action pla

Detroit Wayne Integrated Health Network

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