Compliance Review Specialist

The Compliance Review Specialist is responsible for supporting Heartshares regulatory and billing compliance efforts. This role conducts audits monitors corrective measures ensures documentation accuracy and supports adherence to Federal State City and Agency regulatory standards. The Compliance Review Specialist works collaboratively with program staff leadership and external oversight agencies to promote compliance reduce risk and improve operational effectiveness.

Primary Responsibilities and Essential Functions of Position:

Compliance & Case Record Reviews

• Conduct record reviews (manual and electronic) to ensure compliance with Heartshare policy Medicaid Office for People with Developmental Disabilities (OPWDD) Department of Health (DOH) Office of Mental Health and Hygiene (OMH) Administration for Children Services (ACS) regulatory and quality standards.
• Schedule and complete clinic case record reviews ensuring all encounters notes and assessments are accurate complete and aligned with treatment plans.
• Conduct Childrens Community Residences(CCR) and Medicaid Billing case record reviews ensuring documentation is thorough compliant and audit ready.
• Monitor for documentation discrepancies including duplications and potential fraudulent entries.
• Generate audit reports and track corrective actions to ensure ongoing compliance and effectiveness.
• Participate in state and federal audits as a support and liaison for the program

Billing Compliance & OMIG Oversight

• Conduct Office of Medicaid Inspector General (OMIG) billing reviews for clinic and CCR programs to ensure all claims meet regulatory requirements and are billed timely.
• Identify discrepancies and coordinate necessary follow-up actions including self-disclosures.
• Complete monthly self-disclosures for voided claims in collaboration with the Billing Compliance Officer.
• Work with program teams to review billing practices and gather documentation for compliance review.

Reporting & Quality Improvement

• Run and analyze reports on program compliance with corrective action and performance improvement plans.
• Provide recommendations to improve program performance and reduce risk based on audit outcomes and identified trends.
• Track and monitor corrective actions to ensure timely resolution and sustained compliance.

Training Safety & Program Support

• Provide staff training on compliance standards and best practices.
• Support programs in maintaining compliance with all applicable rules regulations and agency policies.

Additional Responsibilities

• Serve on committees assigned relevant to agency compliance.
• Respond to leadership requests in a timely and professional manner.

• Bachelors degree in health administration Social Work Public Health or related field (preferred).
• Knowledge of Medicaid ACS OMIG OMH OPWDD and DOH regulations and compliance requirements.
• 2-5 years experience in case review QA/Compliance or similar roles.
• Experience with billing and EHR systems (e.g. Precision Care Asara Millin) a plus
• Strong attention to detail analytical skills and organizational abilities.
• Excellent communication and interpersonal skills.
• Ability to work collaboratively across teams and programs.

Benefits

At HeartShare we offer a comprehensive benefit package based on full-time/part-time status. You canexpect:

• Rewarding Work in a team environment.
• Paid vacation sick personal days and holidays.
• 403(B) retirement plans with employer contribution.
• Health dental vision and life insurance.
• Employee Assistance Program (EAP).
• Flexible spending account (Dependent Care Medical Parking and Transit).
• Employee Appreciation Programs and Events.
• Tuition Assistance Program.
• Professional Development opportunities.
• Wellhub Discount
• Verizon Wireless Discount.
• BJs Membership discount.
• Discounts on Broadway tickets movie tickets theme parks sporting events gift certificates & more

HeartShare is an Equal Opportunity Employer (EOE). If you need to request accommodation during the recruiting process please reach out to.

About Heartshare

Who WE ARE:

For over 150 years Heartshare has been dedicated to championing and empowering New Yorkers society has too often overlooked and underestimated.

To learn more about HeartShare please visit our website Follow us onTwitterLinkedInYouTubeInstagramFacebook

HeartShare Human Services of New York Homepage

HeartShare Human Services of New York nurtures and empowers children and adults with intellectual and developmental disabilities.