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CORPORATE COMPLIANCE REVIEWER
TITLE: CORPORATECOMPLIANCEREVIEWER–Fraud & Abuse(Licensed)
HOURS: 8:00am–5:00pm M-F
• Assists the Corporate Compliance Officer with development, revision and maintenance of policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct.
• Assists the Corporate Compliance Officer with developing, coordinating, and participating in a multifacetededucationalandtrainingprogramthatfocusesonthecomplianceprogramsothat MCOemployees,NetworkProviders,andenrolleesareknowledgeableof,andcomplywith,pertinentfederalandstatestandards.
• Completion ofclinicalreviewsoccurringasaresultofsanctionsappliedtoNetwork providersforreasonsofsuspectedfraud,wasteandabuse(i.e.pre-pay reviews) orasapart ofaninvestigationintoallegationsor suspected fraud, waste and abuse (i.e. clinical review of enrollee records including servicedocumentation,clinicalcomprehensiveassessmentsandtreatmentauthorizationrequests).
• Maintains a current working knowledge of Federal and State regulations and policies as they affect the
MCO and its Network Providers.
• Completes compliance research on specific topics, such as Privacy regulations, Conflict of Interest
Standards, and provides examples of industry risk analysis as requested.
• Conductsresearchonindustrycomplianceeducationandreference documents. Summarizesinformationintoa formatformeetingandpresentationpurposes.
• Performs internal and external compliance reviews and monitors activities, including periodic reviews
(administrative and clinical) of departments and Network Providers.
• Supports investigations and matters related to compliance, including the flexibility to design andcoordinateinternalinvestigations(e.g.respondingtoreportsofproblems,hot-linecalls,or suspectedviolations)andanyresultingcorrectiveactionswithemployeesandNetworkProviders.
• MonitorstheperformanceoftheComplianceProgramandrelatesactivitiesonacontinuing basis,takingappropriatestepstoimproveitseffectiveness.
• Performs related tasks as required.
Master’sdegree required with demonstratedknowledgeof operational,financial,quality assurance,and human resource procedures andregulations and three to five(3-5)years’experience in a health care organization. Corporate Compliance Experience ina customer-services focused environment. Possession of Valid North Carolina professional clinical licensure in behavioral health field (LCSW,LPC,LPA) issued by the State of North Carolina is REQUIRED. Must possessa valid North Carolina driver’s license.
SubmissionofanoriginalCenterPointHuman Servicesapplicationisrequired.Ifanoffer of employmentisextended,
verificationof educationandclinical licensuremustbe submittedpriortobeginningwork.Anapplicationmaybeobtained fromthewebsiteatwww.cphs.organdsubmittedto: