Medical Policy & Compliance Specialist

The Medical Policy & Compliance Specialist is responsible for researching, analyzing, and interpreting CMS (Medicare) and state Medicaid guidelines to ensure the organization's processes and procedures adhere to established rules and evolving legislation. This role serves as an internal subject matter expert on healthcare payer policies to develop and update billing procedures, assist with provider inquiries, identify compliance risks areas, and support process improvement initiatives across the company. 

Salary: $110,000/Annually 

The Medical Policy & Compliance Specialist responsibilities include but are not limited to:
 

• Deep knowledge of CMS, state Medicaid, and NCQA regulations relevant to Utilization Management (UM), Credentialing and Claims, with the ability to translated them into operational requirements
• Strong understanding of DME billing guidelines, medical necessity criteria, coding protocols (ICD-10, HCPCS, modifiers, non-covered codes) from an operational compliance and policy perspective
• Ability to proactively monitor regulatory changes, assess downstream operational impacts, and recommend timely updates to policies and procedures
• Skilled in audit preparation and mock reviews to ensure readiness for NCQA, CMS, Medicaid and external health plan audits
• Strong analytical and problem-solving skills with the ability to spot compliance risk and propose actionable solutions
• Excellent written and verbal communication skills and ability to explain complex regulatory requirements in clear, practical terms to staff and leadership
• High organized and detail oriented with the ability to manage multiple priorities independently in a lean team environment
• Comfortable functioning as the primary operational compliance resource while collaborating effectively with UM, Credentialing, Claims, Business Intelligence and other teams
• Proficiency in Microsoft Office applications, specifically intermediate Excel or equivalent data analysis skills preferred

EDUCATION: Bachelor’s degree required, Master’s degree preferred

EXPERIENCE:

• Minimum 3 years experience in healthcare compliance, regulatory affairs, and/or utilization management within a health plan or managed care environment
• Demonstrated expertise in CMS and state Medicaid regulations with the ability to translate policy into operational requirements for UM, Cred and Claims
• Proven ability to proactively monitor, analyze, and respond to regulatory changes, including developing policy/procedure updates and staff guidance
• Strong collaboration with cross functional teams to resolve operational compliance issues and strengthen processes
• Experience working independently in small or lean team environment, balancing multiple priorities and serving as the primary operational compliance resource
• Excellent analytical, problem solving, and written/verbal communication skills, intermediate Excel and data analysis skills are preferred

WHAT WILL YOU LEARN IN THE FIRST 6 MONTHS?

• Become self sufficient in the UM system and core UM, Credentialing and Claims workflows
• Stand up a regulatory monitoring cadence (CMS updates, state Medicaid portals, NCQA updates, etc.) to track changes impacting operations
• Begin delivering compliance summaries and recommendations to leadership and frontline teams  Conduct initial mock audits checks again UM and Cred process to identify baseline gaps and risk
• Build relationships with UM, Credentialing, Claims, & Business Intelligence teams to establish yourself as the go to operational compliance resource
• Support early implementation activities by reviewing requirements and flagging regulatory considerations before go live

WHAT WILL YOU ACHIEVE IN THE FIRST 12 MONTHS?

• Demonstrate subject matter expertise in CMS and state Medicaid guidelines, including their operational impact on UM and Credentialing
• Expand working knowledge of ICD-10, HCPCS, and DME billing protocols to interpret regulatory requirements (not day to day coding)
• Establish a structured process to proactively monitor CMS, state Medicaid, and regulatory updates that impact UM, Credentialing and Claims operations
• Support preparation for external audits by conducting mock reviews and ensure required compliance documentation is in place
• Identify process improvement opportunities that reduce compliance risk or improve regulatory alignment
• Actively support new client implementations by ensuring operational workflows and policies are aligned with payer and accreditation requirements from the outset
• Maintain expected timelines while demonstrating the ability to anticipate and respond quickly to new or revised regulations

Benefits Offered

• Competitive compensation and annual bonus program
• 401(k) retirement program with company match
• Company-paid life insurance
• Company-paid short term disability coverage (location restrictions may apply)
• Medical, Vision, and Dental benefits
• Paid Time Off (PTO)
• Paid Parental Leave
• Sick Time
• Paid company holidays and floating holidays
• Quarterly company-sponsored events
• Health and wellness programs
• Career development opportunities

Remote Opportunities

We are actively seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Vermont, and Washington.

Our Story

Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits. Integra Partners is a wholly owned subsidiary of Point32Health.

With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We’re looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.

Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.