Compliance & Investigations Manager

• Conduct complex compliance, operational, privacy, billing, coding, and risk-management investigations across multiple healthcare settings.
• Manage cases originating from compliance hotlines, risk-management event reports, leadership referrals, regulatory concerns, internal audits, and other sources.
• Conduct witness and claimant interviews, review documentation, analyze evidence, and prepare detailed investigative reports and executive summaries.
• Ensure investigations are objective, thorough, confidential, timely, and consistent with organizational policies and regulatory requirements.
• Track and analyze investigation activity to identify recurring compliance, operational, fraud, and patient-safety risks.
• Perform detailed root-cause analyses to identify process failures, operational breakdowns, and systemic vulnerabilities.
• Develop actionable corrective action plans and risk-mitigation recommendations to reduce future exposure and improve operational performance.
• Partner with operational leaders and cross-functional teams to implement process improvements and monitor the effectiveness of mitigation strategies.
• Review allegations and event reports for potential regulatory, billing, coding, fraud, waste and abuse, HIPAA/privacy, and operational compliance concerns.
• Analyze healthcare billing and coding documentation to identify potential compliance or reimbursement risks.
• Support assessments of operational practices against CMS requirements, healthcare regulations, accreditation standards, and internal policies.
• Support regulatory-readiness activities and operational compliance reviews across outpatient, physician practice, ambulatory, rehabilitation, and hospital-based healthcare environments.
• Prepare executive-level findings, trend reports, risk analyses, recommendations, and other materials for leadership.
• Collaborate with Compliance, Risk Management, Revenue Cycle, Legal, Human Resources, Operations, and Clinical teams on investigations and corrective actions.
• Participate in organizational risk assessments, audits, and compliance initiatives.
• Support workers’ compensation claim investigations by reviewing injury reports, statements, incident documentation, and relevant claims history.
• Interview injured employees, supervisors, and witnesses to establish facts and assess potential liability.
• Serve as a liaison between injured employees, management, insurance carriers, third-party administrators, and legal teams.
• Coordinate return-to-work processes, including light-duty assignments and modified work plans, in collaboration with HR and safety personnel.
• Maintain accurate electronic case documentation, updates, diary dates, and milestones within risk-management systems.
• Complete required initial contacts and statutory filings within applicable legal deadlines.
• Gather and organize discovery materials and support legal counsel with hearings and case preparation.
• Attend mediations, settlement conferences, appeals-board hearings, and other legal proceedings when required.
• Analyze workers’ compensation claim trends and prepare reports that identify safety risks, recurring hazards, and potential cost-saving opportunities.

Requirements

• Bachelor’s degree in Healthcare Administration, Nursing, Business Administration, Compliance, Legal Studies, or a related field.
• Minimum of 5 years of experience in healthcare compliance, healthcare investigations, risk management, auditing, revenue integrity, or a related healthcare regulatory function.
• Demonstrated ability to independently conduct complex healthcare investigations from intake through resolution and reporting.
• Strong analytical, investigative, interviewing, documentation, and problem-solving capabilities.
• Ability to identify systemic operational risks, determine root causes, and recommend practical corrective actions.
• Strong working knowledge of healthcare billing and coding practices.
• Knowledge of CMS regulations and healthcare regulatory requirements.
• Strong understanding of HIPAA and healthcare privacy requirements.
• Knowledge of fraud, waste, and abuse concepts and related compliance risks.
• Understanding of healthcare operational workflows and risk-management practices.
• Experience working across multiple healthcare environments, such as outpatient clinics, physician practices, hospital-based departments, ambulatory care, or rehabilitation services.
• Excellent written and verbal communication skills, with the ability to produce clear investigative documentation and executive-level reporting.
• Strong interviewing skills and the ability to evaluate conflicting information objectively.
• Ability to handle sensitive and confidential information with discretion and professionalism.
• Strong organizational skills and the ability to manage multiple investigations, cases, deadlines, and priorities independently.
• Ability to collaborate effectively with senior leaders and cross-functional teams, including Legal, HR, Compliance, Revenue Cycle, Operations, and Clinical stakeholders.
• Sound judgment, intellectual curiosity, attention to detail, and a proactive approach to identifying emerging risks.

Benefits

• Annual salary of $90,000–$95,000, with actual compensation determined by factors such as experience, background, and work location.
• Fully remote position within the United States.
• Opportunity to work across multiple healthcare environments and functional areas.
• Broad exposure to healthcare compliance, investigations, operational risk, regulatory readiness, and workers’ compensation.
• Opportunity to influence corrective actions, process improvements, and enterprise risk-reduction strategies.
• High-visibility role involving collaboration with operational leaders and senior cross-functional stakeholders.
• Opportunity to contribute to initiatives that strengthen regulatory compliance, operational performance, and patient safety.
• Professional environment focused on quality, accountability, collaboration, and continuous improvement.