BA/BS degree with 5+ years in healthcare regulatory, compliance, auditing or privacy roles; equivalent experience may be considered.
Experience with managed care, utilization management, care management, or PBM environments.
Proven experience managing multi-state licensure processes related to UR/PBM.
Strong organizational skills with a focus on meeting tight deadlines.
Demonstrated capability in conducting regulatory audits and overseeing compliance programs.
Detail-oriented with solid analytical skills and knowledge of US healthcare regulatory frameworks.
Responsibilities
Support the ongoing development of the corporate compliance program.
Monitor healthcare regulations and assess their impact on the organization.
Ensure adherence to applicable laws and contractual commitments with stakeholders.
Conduct internal audits across various functional areas.
Prepare and submit filings for Utilization Review licenses across relevant states.
Assist in developing and delivering compliance training programs.
Evaluate compliance risks and trends throughout the organization.
Benefits
Flexible remote work arrangement with occasional travel to headquarters.
Opportunity to influence a culture of compliance and ethical conduct.
Engagement in a diverse range of compliance and regulatory activities.
Potential for professional development in regulatory and auditing skills.
Full Job Description
In this role you will be responsible for:
Corporate Compliance
Support the development, implementation and continuous improvement of the corporate compliance program.
Monitor changes in healthcare regulations and collaborate with the appropriate stakeholders to assess organizational impact.
Partner with the appropriate internal stakeholders to ensure compliance with applicable laws, standards and contractual commitments.
Assist in risk assessments and compliance program effectiveness evaluations.
Maintain and update policies, procedures, and compliance documentation.
Internal Audits & Audit Readiness
Support the execution of client audits and audit readiness activities includes providing guidance to internal stakeholders on oversight audit design and execution.
Develop audit tools and methodologies consistent with industry best practices and regulatory/accreditation requirements.
Evaluate compliance with regulatory standards such as CMS, state DOI, URAC and NCQA where applicable.
Document audit findings, identify root causes and provide actionable recommendations.
Collaborate with internal and external stakeholders to manage corrective action plans (CAPs) through closure.
Maintain audit schedules and ensure timely completion of all oversight activities.
Conduct internal audits across functional areas (i.e. operations, clinical programs, HR/HCM, IT/Information Security).
Perform ongoing monitoring activities to identify compliance risks and trends.
Prepare comprehensive audit reports and present findings to internal stakeholders and leadership.
Support enterprise risk management initiatives as needed.
Prepare and submit initial, renewal, and amendment filings for Utilization Review (UR) licenses across all applicable state jurisdictions, ensuring accuracy, completeness, and compliance with varying regulatory requirements and deadlines.
Demonstrate strong knowledge of UR licensure requirements, including applicability by line of business, and interpret state-specific URA regulations to ensure compliant filings.
Validate filings against applicable states, CMS, URAC, and NCQA accreditation standards.
Maintain compliance calendars and serve as primary liaison with state regulatory agencies and licensing bodies.
Monitor and respond to state regulator inquiries, deficiency notices, and documentation requests.
Evaluate entity structure changes (e.g., name changes, EIN changes, ownership changes) for licensure impact and required filings.
Support and respond to external audits.
Conduct 50-state regulatory research to identify licensure requirements, applicability, and compliance obligations.
Maintain and update state-specific Utilization Management (UM) policies and procedures, ensuring alignment with regulatory requirements and operational practices.
Training & Education
Assist in developing and delivering compliance training programs.
Promote a culture of compliance and ethical conduct throughout the organization through compliance communications and presentations.
Coordinate the collection, validation, and reporting of statistical data required for licensure filings, audits, and regulatory reporting.
Other Duties: Perform additional tasks as assigned.
QUALIFICATIONS
Required: [minimum education, certifications, and experience needed]
Requires a BA/BS and minimum of 5 years health care, regulatory, ethics, auditing, compliance or privacy experience; or any combination of education and experience, which would provide an equivalent background.
Experience with managed care, utilization management, care management, PBM or health plan environments.
