Compliance & Investigations Manager

The Compliance & Investigations Manager supports PT Solutions' Compliance and Risk Management functions through oversight and execution of complex investigations, operational risk reviews, and regulatory compliance assessments.

This role conducts thorough investigations related to compliance hotline reports, risk management events, billing and coding concerns, regulatory matters, and operational issues across multiple healthcare settings.

The Compliance & Investigations Manager is expected to perform deep-dive analyses to identify root causes, operational vulnerabilities, systemic trends, and opportunities for process improvement.

Essential Functions

Investigations & Case Management

• Conduct complex compliance, operational, privacy, billing, coding, and risk management investigations across multiple healthcare settings.
• Manage investigations from various sources, including the Compliance Hotline and internal audits.
• Conduct witness interviews, review documentation, and prepare detailed investigation reports.
• Ensure investigations are thorough, objective, confidential, and in accordance with organisational policies and regulatory expectations.
• Track and trend investigation activity to identify recurring risks.

Root Cause Analysis & Operational Improvement

• Perform detailed root cause analyses to identify underlying process failures and systemic vulnerabilities.
• Develop actionable recommendations and corrective action plans to reduce future risk exposure and improve operational performance.
• Collaborate with operational leaders to implement process improvements and monitor effectiveness of mitigation strategies.

Regulatory Compliance & Risk Management

• Review allegations and event reports for potential regulatory, billing, coding, or operational compliance concerns.
• Analyse healthcare billing and coding documentation for potential compliance or reimbursement risk.
• Assist in evaluating operational practices to ensure compliance with CMS requirements and healthcare regulations.

Reporting & Collaboration

• Prepare executive-level summaries, investigation findings, and recommendations for leadership review.
• Partner with various departments on investigations and corrective actions.

Workers Compensation job duties:

• Claim Investigation & Liability Assessment: Review injury reports, conduct investigations, and evaluate claims history.
• Case Management & Coordination: Serve as liaison between injured teammates, management, and insurance carriers.
• Compliance, Litigation & Reporting: Adhere to timelines, maintain electronic documentation, and support legal counsel.

Required Skills & Abilities

• Strong analytical, interviewing, and problem-solving skills.
• Ability to identify systemic operational risks and recommend corrective actions.

Required Credentials

• Bachelor’s degree in Healthcare Administration, Nursing, Business Administration, Compliance, or related field.
• Minimum of five years of experience in healthcare compliance, investigations, risk management, or related role.
• Demonstrated experience conducting complex healthcare investigations independently.
• Strong working knowledge of healthcare billing and coding, CMS regulations, HIPAA/privacy requirements, and fraud, waste, and abuse concepts.

Compensation:

• $90,000 - 95,000 annually