Clinical Compliance Analyst, RN in Pinehurst, North Carolina at FirstHealth of the Carolinas

Corporate Compliance Officer

This indicates the position functions within the organization's compliance structure and supports enterprise-wide compliance initiatives, audits, investigations, and regulatory monitoring.

None

The position does not directly supervise staff but serves as a subject matter expert and advisor to leadership, providers, and employees.

• All departments, management, providers, and employees throughout the organization.
• Clinical and administrative staff across various locations and departments.

• Bachelor's degree in nursing (BSN).
• Active North Carolina Registered Nurse (RN) license.

One of the following:

• 3-5 years of progressive nursing management experience, or
• 10+ years of experience in a similar clinical compliance, quality, utilization management, or regulatory role.

• Medicare and Medicaid coverage guidelines.
• Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
• Healthcare reimbursement practices.
• CPT coding and medical coding principles.

• Proficiency with Microsoft Word, Microsoft Excel and EPIC
• Office automation and personal computer proficiency.
• Email and reporting applications.

• Working knowledge of HIPAA privacy and security requirements.
• Understanding healthcare compliance standards and regulatory expectations.

• Strong verbal and written communication skills are important.
• Ability to work closely with multiple departments across the organization and non-FHC clinics such as PMC, PSC, CEA, etc.
• Commitment to customer service and fostering positive team relationships.
• Ability to educate, influence, and collaborate with clinical and administrative staff.

• Analytical and statistical problem-solving abilities.
• Experience reviewing data, identifying trends, and evaluating compliance risks.
• Ability to interpret findings and make practical recommendations.

• Ability to identify operational or compliance issues.
• Demonstrated skills in developing creative, effective solutions.
• Sound judgment and critical thinking abilities.

• Strong attention to detail.
• Ability to prioritize multiple projects and responsibilities.
• Ability to meet deadlines and manage time effectively.

• Assist in developing, updating, and maintaining compliance with policies and procedures.
• Support implementation and ongoing monitoring of the organization's corporate compliance plan.
• Evaluate audit processes and compliance goals and recommend improvements when needed.
• Apply structured problem-solving methods to address compliance and operational issues.

• Plan and perform financial, operational, and compliance audits.
• Analyze data, evaluate findings, and communicate audit results objectively and impartially.
• Monitor medical necessity, clinical documentation, coding, and billing practices.
• Conduct inpatient and outpatient chart reviews.
• Participate in compliance monitoring activities and internal audits.
• Assist with investigations involving suspected non-compliance and support of corrective action implementation.
• Maintain confidentiality throughout audit and investigative processes.

• Prepare reports related to audits, monitoring activities, investigations, and regulatory requirements.
• Provide information that supports management of decision-making, risk reduction, and operational effectiveness.
• Document audit testing, findings, recommendations, and supporting work papers thoroughly.
• Maintain accurate records and compliance documentation.

• Develop educational materials related to compliance, documentation, coding, and regulatory requirements.
• Provide guidance to employees, leadership, and medical staff on compliance-related matters.
• Support organization-wide training regarding ethical conduct, legal requirements, and regulatory standards.
• Promote a culture of compliance and accountability.

• Strong analytical, critical thinking, and problem-solving abilities.
• Ability to identify compliance risks and develop practical corrective actions.
• Attention to detail and accuracy in audit documentation.
• Effective verbal and written communication skills.
• Sound judgment and ability to provide unbiased evaluations.
• Strong organizational skills and ability to manage multiple deadlines.