Clinical Compliance Coordinator

Clinical Compliance Coordinator

Prompt Care is looking for a Clinical Compliance Coordinator to support clinical review and regulatory compliance within the Intake & Resupply department. This full-time hybrid role is responsible for evaluating medical documentation to determine eligibility, coverage, and medical necessity in accordance with Medicare, CMS guidelines, and payer policies. The ideal candidate will have experience in Medicare Advantage or managed care, strong knowledge of Medicare regulations, and the ability to interpret medical records, identify documentation gaps, and support appeals while ensuring full compliance.

Job Type: Full time/ Hybrid

Job Location: hybrid 2 days per week in King of Prussia, PA

• The Clinical Compliance Coordinator is responsible for evaluating clinical information to determine member eligibility, coverage, and medical necessity in accordance with Medicare regulations, CMS guidelines, and organizational policies.
• This role ensures compliance with federal requirements while supporting high-quality, cost-effective patient care.
• Provide feedback and guidance for a written appeals process to overturn authorization denials.
• Effectively identify missing or non-complaint documentation required under CMS guidelines and published medical policies for governmental and commercial payers.

• Prior experience in Medicare Advantage or managed care organizations
• Certification in Case Management (CCM), Utilization Review (CPUR), or equivalent
• Experience with audits, appeals, and regulatory compliance
• Administrative focus with Clinical background
• Minimum 2–5 years of experience (acute care, managed care, or Medicare populations preferred)
• Strong knowledge of Medicare Parts A, B, C, and/or D
• Experience with utilization management, case management, or clinical review
• Familiarity with CMS regulations, medical necessity criteria, and evidence-based guidelines (Inter Qual, MCG, or similar)
• Strong analytical, documentation, and communication skills
• Proficiency with electronic medical records and clinical review systems
• Ability to interpret medical records, particularly chart notes including test results, diagnosis, medical verbiage pertaining to CMS guidelines
• Must be able to interpret and comprehend published payer medical policies
• Determine Contraindicators within published medical policies for acceptance while maintaining compliance practices
• Comprehensive Medical, Dental, and Vision Package
• 401(k) Plan with Company Match
• Generous PTO:
  Vacation, Sick Time, Personal Days, and Paid Holidays
• Life Insurance:
  Standard coverage with optional enhancements
• Employee Assistance Program:
  Free counseling and coaching sessions
• Emotional Well-being and Work-Life Balance Resources
• Short & Long-Term Disability:
  Company-paid with optional supplements
• Accidental Death and Dismemberment Insurance
• FSA and HSA:
  Manage healthcare expenses
• Commuter Spending Programs
• Volunteer and Engagement Opportunities
• Exclusive Discounts on entertainment, travel, and various other supplemental and cellphone plans

The Prompt Care Companies is committed to Equal Employment Opportunity (EEO) and prohibits employment discrimination on the basis of race, color, age, national origin, religion, gender, gender identity, sexual orientation, pregnancy, marital status, genetic disposition, disability, veteran's status or any other characteristic or classification protected by State/Federal/Local laws. We foster a work environment in which diversity and inclusion are embraced, people are hired and advanced on their merits, and employees are treated with mutual respect and dignity.