Medical Policy & Compliance Specialist

Remote
Full Time
Utilization Management
Experienced
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.

Share

Apply for this position

Required*
Apply with Indeed
We've received your resume. Click here to update it.
Attach resume or Paste resume
Attach resume as .pdf, .doc, .docx, .odt, .txt, or .rtf (limit 5MB) or Paste resume

Paste your resume here or Attach resume file

To comply with government Equal Employment Opportunity and/or Affirmative Action reporting regulations, we are requesting (but NOT requiring) that you enter this personal data. This information will not be used in connection with any employment decisions, and will be used solely as permitted by state and federal law. Your voluntary cooperation would be appreciated. Learn more.
Invitation for Job Applicants to Self-Identify as a U.S. Veteran
  • A “disabled veteran” is one of the following:
    • a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
    • a person who was discharged or released from active duty because of a service-connected disability.
  • A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
  • An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
  • An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Veteran status


Voluntary Self-Identification of Disability
Voluntary Self-Identification of Disability Form CC-305
OMB Control Number 1250-0005
Expires 04/30/2026
Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

  • Alcohol or other substance use disorder (not currently using drugs illegally)
  • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
  • Blind or low vision
  • Cancer (past or present)
  • Cardiovascular or heart disease
  • Celiac disease
  • Cerebral palsy
  • Deaf or serious difficulty hearing
  • Diabetes
  • Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
  • Epilepsy or other seizure disorder
  • Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
  • Intellectual or developmental disability
  • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
  • Missing limbs or partially missing limbs
  • Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
  • Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
  • Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
  • Partial or complete paralysis (any cause)
  • Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
  • Short stature (dwarfism)
  • Traumatic brain injury
Please check one of the boxes below:

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

You must enter your name and date
Human Check*