Quality & Compliance Specialist

Confidential Employer | North Carolina
Remote with Monthly Travel to Eastern North Carolina
Full-Time or Part-Time/Fractional Opportunity

A growing behavioral health organization serving North Carolina Medicaid members is seeking an experienced Quality & Compliance Specialist to lead quality assurance, regulatory compliance, utilization review, and audit readiness.

This role is ideal for a proactive compliance professional who understands NC Medicaid, LME/MCOs, Tailored Plans, DHHS requirements, clinical documentation, and behavioral health billing compliance. You do not wait for an audit to uncover a problem. You know how to identify risks, strengthen processes, and help teams correct concerns before they become findings.

What You'll Do

• Conduct clinical documentation reviews and ongoing chart audits

• Manage the organization's Quality Assurance and Quality Improvement Plan

• Prepare for Medicaid, MCO, DHHS, DHSR, and other regulatory audits

• Identify compliance risks and develop corrective action plans

• Monitor corrective actions through completion

• Track documentation trends and recurring compliance concerns

• Monitor regulatory updates from NC Medicaid, DHHS, Tailored Plans, and LME/MCOs

• Maintain compliance policies, procedures, and staff guidance

• Review service authorizations and reauthorizations to prevent coverage gaps

• Partner with billing to address documentation, denial, and reimbursement concerns

• Confirm that billed services are supported by compliant documentation

• Manage client grievances and compliance-related complaints

• Monitor required reporting, including NC IRIS and NC TOPPS

• Support compliant EHR workflows and system improvements

• Provide leadership with regular compliance findings, trends, and recommendations

What We're Looking For

• Bachelor's degree in Human Services, Healthcare Administration, Behavioral Health, Social Work, or a related field; equivalent relevant experience may be considered

• At least three years of experience in behavioral health Medicaid compliance, QA/QI, utilization review, or a related role with a North Carolina provider

• Strong knowledge of NC Medicaid behavioral health requirements, including Clinical Coverage Policy 8A

• Understanding of outpatient mental health and substance use services, documentation standards, staffing, and credentialing

• Experience with NC LME/MCOs, Tailored Plans, NCTracks, and authorization systems

• Experience preparing for Medicaid, MCO, DHHS, or similar regulatory audits

• Experience developing and monitoring corrective action plans

• Strong understanding of clinical documentation and billing compliance

• Ability to translate regulatory requirements into practical policies and workflows

• Strong communication, organization, and analytical skills

• Ability to work independently and follow compliance concerns through resolution

Preferred Experience

• Behavioral health compliance or QA/QI leadership

• Substance use treatment programs

• NC TOPPS and NC IRIS reporting

• EHR implementation or optimization

• CARF or similar accreditation standards

• Policy development and compliance training

• Compliance dashboards and reporting tools

• CHC, CPHQ, or similar quality or compliance certification

Compensation

Full-Time: $60,000–$95,000 annually, depending on experience and qualifications.

Benefits include health, dental, and vision coverage; paid time off; mileage reimbursement for required travel; and professional development support.

Part-Time/Fractional Contractor: $35–$75 per hour, depending on experience and scope.

Location and Travel

This is a remote-first position for candidates residing in North Carolina. Travel to Eastern North Carolina is required at least once per month and occasionally for audits, site reviews, training, and leadership meetings.

Candidates located in Eastern North Carolina are strongly preferred. Reliable transportation and successful completion of required Medicaid exclusion screenings are required.

Ready to Apply?

Please submit your resume and a brief summary of your experience with North Carolina Medicaid behavioral health compliance, quality assurance, and regulatory audits.

The employer's identity will be shared with qualified candidates as they advance through the recruitment process.

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