Healthcare Compliance Officer

Healthcare Compliance Officer

Job Description Summary

The Healthcare Compliance Officer is a strategic leadership role responsible for ensuring the organization operates within all applicable federal, state, and local healthcare regulations. This individual will design, implement, and oversee a comprehensive compliance program tailored to the complexities of the American healthcare system. Working closely with internal and external stakeholders, the Healthcare Compliance Officer fosters a culture of integrity, ensures adherence to legal and regulatory standards, and proactively identifies and mitigates compliance risks.

Experience Must Haves

• Compliance Program Leadership: Demonstrated experience in creating, implementing, and managing compliance frameworks in the U.S. healthcare industry, ensuring adherence to HIPAA, HITECH, ACA, Stark Law, and other regulations.

• Policy and Procedure Management: Proven track record in drafting, implementing, and updating compliance-related policies and procedures, including standards for handling claims, appeals, and member inquiries.

• Regulatory Liaison: Experience acting as a primary point of contact with federal and state regulators (e.g., CMS, HHS, OCR) and successfully managing audits, investigations, and compliance certifications.

• Claims and Appeals Oversight: Extensive knowledge of claims processing, appeals, and grievances, ensuring compliance with ACA and state-specific requirements.

• Fraud, Waste, and Abuse (FWA) Prevention: Expertise in developing programs to detect, prevent, and address FWA in healthcare operations.

Experience Preferred

• Healthcare Technology and Data Security: Strong understanding of compliance with HIPAA Security Rules, the 21st Century Cures Act, and secure implementation of EHR and telehealth systems.

• Member and Provider Relations: Experience ensuring compliance in member and provider communications, marketing materials, and disclosures, with the ability to address complaints effectively.

• Healthcare Risk Management: Comprehensive experience in identifying and mitigating risks across clinical, operational, and business functions in a highly regulated healthcare environment.

• Cross-Functional Collaboration: Proven ability to work with legal, IT, and operational teams to integrate compliance seamlessly into workflows.

Experience & Skill Requirements

• Compliance Program Leadership (10 years): Proven experience in creating and managing compliance frameworks within the U.S. healthcare industry. Strong track record of aligning compliance programs with regulatory standards such as HIPAA, HITECH, ACA, Stark Law, Anti-Kickback Statute, and False Claims Act.

• Regulatory Liaison (8 years): Significant experience interfacing with regulatory agencies (e.g., CMS, HHS, OCR) and managing audits, inquiries, and investigations. Expertise in preparing and submitting compliance reports, certifications, and disclosures.

• Claims and Appeals Oversight (8 years): In-depth knowledge of claims processing, appeals, and grievance management. Ability to monitor adherence to ACA and state-specific healthcare regulations while identifying and addressing non-compliance trends.

• Healthcare Fraud, Waste, and Abuse (FWA) Prevention (8 years): Demonstrated success in implementing robust FWA detection and prevention programs, coordinating investigations, and collaborating with legal teams to resolve incidents and submit regulatory reports as required.

• Policy and Procedure Management (8 years): Extensive experience in drafting, updating, and enforcing compliance-related policies and procedures, with specific expertise in operational workflows related to claims, appeals, and patient/member interactions.

• Healthcare Technology and Data Security (5 years): Experience ensuring compliance with HIPAA Security Rules and the 21st Century Cures Act, particularly in managing electronic health records (EHRs), telehealth systems, and interoperability requirements.

• Cross-functional collaboration: Strong ability to work across legal, IT, clinical, and operational teams to integrate compliance seamlessly into organizational processes. Proven leadership in fostering collaboration to support organizational objectives.

• Analytical and Problem-Solving Skills: Exceptional ability to assess complex compliance scenarios, identify risks, and implement effective corrective action plans. A data-driven approach to decision-making is preferred.

• Healthcare Expertise: Deep understanding of U.S. healthcare systems, payer models (Medicare, Medicaid, and commercial insurers), and accreditation standards such as The Joint Commission (TJC) and NCQA. Experience in ensuring compliance with value-based care initiatives is a plus.

• Leadership and Communication: Proven leadership skills with a track record of building and managing teams. Excellent written and verbal communication skills to effectively convey compliance priorities to diverse internal and external stakeholders.

• Automation and Technology: Experience using compliance management tools and technologies to streamline monitoring, reporting, and incident response. Familiarity with artificial intelligence (AI)-based solutions for healthcare compliance is a bonus.

• Certifications: Certification in healthcare compliance (e.g., CHC, CHPC, or equivalent) is required. Advanced certifications such as CCEP, CISM, or CISSP are highly desirable for candidates with broader regulatory and technical expertise.

About Fortellar

We are a boutique IT consulting and business process outsourcing organization supporting mid to enterprise-level organizations. We are a small, but mighty, team of experts who know how to stretch, adapt, and put on any hat required at the moment to make our clients successful and enable Fortellar’s growth. Keys to success at Fortellar include:

• Collaboration: You demonstrate excellence in remote collaboration across your Fortellar and client teams.

• Growth Mindset: You embrace personal growth and are always learning new things to support your team, your clients, and your personal goals.

• Client Success: You have a passion for your client’s success – you don’t just deliver to the contract you ensure that your client’s goals and needs are met.

• Humanity First: Honest and transparency are your natural instincts – your actions speak louder than your words and your team members love working with you.

• Entrepreneurial: You find a way to get it done, no matter what the challenges or seeming blockers are in front of you

Work Environment

• Remote/Hybrid: Remote

• Travel Requirements: 10 - 15%