Regulatory Compliance Analyst
1 week ago
Position Summary: The Regulatory Compliance Analyst plays a crucial role in ensuring adherence to established guidelines and standards within the organization.
Key Responsibilities:
- Conduct thorough evaluations of clinical and provider documentation, engaging with staff, participants, and stakeholders to assess compliance with Medicaid regulations. This includes determining the validity of Medicaid payments and initiating necessary investigations or educational outreach.
- Perform internal reviews and appeals to verify that actions taken by waiver agents align with contractual, regulatory, and accreditation requirements. This involves scrutinizing case records, assessments, and service plans to address any service provision issues.
- Manage case inquiries and appeals, preparing comprehensive case files for hearings. Attend relevant hearings to present and justify internal decisions to oversight bodies and regulatory agencies.
- Work collaboratively with supervisors and subject matter experts to ensure a clear understanding of compliance standards. Communicate effectively with internal and external parties to finalize decision notices and investigative outcomes.
- Utilize established clinical criteria and relevant resources to craft well-supported correspondence for appeals and investigations. Stay informed about internal policies, accreditation standards, and applicable laws to ensure documentation is current and compliant.
Qualifications:
- For RN candidates: A minimum of an Associate's Degree in Nursing with a valid State of Michigan nursing license is required.
- Experience: A background of 2-4+ years in an administrative clinical environment, including 1-2 years in Medicaid managed care appeals and Health/Human Services.
- Strong interpersonal skills to effectively engage with various stakeholders, including managers, program participants, and community representatives.
- Excellent communication, organizational, and investigative abilities, with a proven track record in conducting clinical reviews and presenting findings.
- Familiarity with community-based services and experience working with older adults or individuals with disabilities is preferred.
- Proficiency in MS Office at an intermediate to advanced level is essential.
Hired In Michigan is actively seeking candidates for direct hire employment opportunities. We specialize in connecting skilled professionals with employers looking for experienced individuals, recent graduates, military veterans, and entry-level candidates.
For more information, please visit our website.
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