The Senior Director, Compliance Officer will lead the organization's compliance strategy and operations, ensuring adherence to federal and state regulations governing the business. This role is critical in maintaining the integrity of the organization's compliance program, fostering a culture of ethics, and mitigating regulatory risk. The position reports directly to the General Counsel and provides regular updates to the Board of Directors.
Key Responsibilities:- Develop, implement, and oversee a comprehensive compliance program aligned with federal and state healthcare regulations, including CMS, HIPAA, and state-specific managed care requirements.
- Monitor and ensure compliance with contractual obligations related to delegated services all Specialties demonstrating and applying knowledge of operations in claims, call center and/or medical management.
- Serve as the Organization's HIPAA Privacy Official and coordinate with the designated HIPAA Security Official on all related matters, as outlined in the HIPAA Privacy & Security Plan.
- Serve as the primary liaison with regulatory agencies and health plan partners regarding compliance matters.
- Lead internal audits and risk assessments to identify potential areas of compliance, vulnerability and risk.
- Develop and deliver compliance training programs for employees, providers, and contractors.
- Investigate and resolve compliance issues, including allegations of misconduct or regulatory violations.
- Collaborate with operational leaders to integrate compliance into business processes and strategic initiatives.
- Prepare and present compliance reports to the General Counsel and Board of Directors, including risk assessments, audit findings, and corrective action plans.
- Stay current with evolving healthcare regulations and industry best practices, advising leadership on necessary changes.
- Oversee the development and maintenance of policies and procedures that promote compliance and ethical conduct.
- Manage budget preparation and adherence to budget for the Compliance department.
- Chair the Compliance Committee and related sub-committees
- Coordinate the oversight activity of affiliated contractors/delegates
- Enhance and maintain a Fraud, Waste and Abuse prevention, detection and operation program
Qualifications:- Bachelor's degree required; JD, MBA, or Master's in Healthcare Administration preferred.
- Minimum of 8 years of experience in healthcare compliance, preferably within managed care or delegated service organizations.
- Deep understanding of regulatory frameworks including CMS, HIPAA, and state Medicaid/Medicare regulations.
- Experience working with delegated services and provider networks.
- Proven ability to lead cross-functional teams and influence organizational change.
- Exceptional communication and presentation skills, with experience reporting to executive leadership and boards.
- Strong analytical and problem-solving skills.
Preferred Skills:- Certification in Healthcare Compliance (CHC) or similar credential.
- Experience with compliance technology platforms and data analytics.
