Senior Compliance Specialist – Payment Integrity

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as the main compliance contact for Payment Integrity and Payment Operations, offering strategic advice on regulatory and operational compliance issues.

• Interpret, analyze, and implement relevant regulatory requirements, including the No Surprises Act (NSA), Fraud, Waste & Abuse (FWA) laws, CMS requirements, and state Department of Insurance (DOI) regulations that affect payment and billing practices.

• Provide oversight and guidance on compliance related to payment workflows, reimbursement methodologies, claims administration processes, and product development initiatives.

• Collaborate across departments with operational leaders to identify, evaluate, and reduce financial and regulatory compliance risks linked to payment and claims functions.

• Monitor and assess new regulatory developments, enforcement trends, and industry guidelines to gauge their operational impact and assist in implementing necessary changes.

• Aid in the creation, review, implementation, and upkeep of financial and payment-related policies, procedures, and standard operating procedures (SOPs).

• Engage in high-risk initiatives, system implementations, process improvements, and product modifications to ensure that compliance considerations are effectively incorporated.

• Support incident response activities related to payment disputes, FWA-related escalations, regulatory inquiries, and other compliance issues.

• Assist in internal audits, external audits, client audits, and regulatory examinations by organizing documentation, addressing inquiries, and ensuring readiness for audits.

• Work with Corporate Compliance and cross-functional teams on issue intake, triage, investigation assistance, tracking, corrective action planning, and resolution efforts.

• Create and provide training, education, and compliance guidance to internal stakeholders about applicable regulatory requirements, policies, and operational expectations.

• Maintain precise and organized documentation that supports compliance oversight activities, monitoring efforts, investigations, and audit preparedness.

⛳️ Requirements

• A Bachelor’s degree is required; a concentration in Healthcare Administration, Finance, Business Administration, or a related field is preferred.

• Over 5 years of progressive experience in healthcare compliance, payment integrity, regulatory compliance, or related healthcare operations.

• Certified Professional Coder (CPC) credential or an equivalent coding certification.

• Proven knowledge and experience with claims processing operations and/or payment integrity programs.

• Demonstrated understanding of healthcare billing, coding, and reimbursement regulations.

• Substantial experience with Fraud, Waste & Abuse (FWA) compliance frameworks and investigative processes.

• Preference for candidates with experience supporting No Surprises Act (NSA) implementation, oversight, and compliance activities, as well as experience in Payment Integrity, health plans, payer-side, or managed care operations.

🏝️ Benefits

• Competitive benefits package with generous employer subsidies.

• Flexible and remote working options.

• 401k with generous employer match and immediate vesting.

• Opportunities for personal and professional development.

• Supportive family benefits, including paid leave for new family members.

• Companywide philanthropic program, Valenz Communities Connection.