Compliance Lead- Remote

Job Summary

The Compliance Lead will help 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.   

Primary Responsibilities

• Program Oversight: Develop, implement, and oversee a comprehensive compliance program aligned with federal and state healthcare regulations, including CMS, HIPAA, and state-specific managed care requirements.
• Delegated Services: Monitor and ensure compliance with contractual obligations related to delegated services across all clinical specialties, demonstrating and applying knowledge of operations in claims, call centers, and/or medical management.
• Privacy Official: Serve as the organization's HIPAA Privacy Official and coordinate with the designated HIPAA Security Official on all related matters, as outlined in the Privacy & Security Plan.
• Regulatory Liaison: Serve as the primary liaison with regulatory agencies and health plan partners regarding compliance matters.
• Audits & Risk Assessment: Lead internal audits and risk assessments to identify potential areas of compliance vulnerability and risk.
• Training & Development: Develop and deliver compliance training programs for employees, providers, and contractors.
• Investigations: Investigate and resolve compliance issues, including allegations of misconduct or regulatory violations.
• Operational Collaboration: Collaborate with operational leaders to integrate compliance into business processes and strategic initiatives.
• Executive Reporting: Prepare and present compliance reports to the General Counsel and Board of Directors, including risk assessments, audit findings, and corrective action plans.
• Regulatory Tracking: Stay current with evolving healthcare regulations and industry best practices, advising leadership on necessary changes.
• Policies & Procedures: Oversee the development and maintenance of policies and procedures that promote compliance and ethical conduct.
• Financial Management: Manage budget preparation and adherence to budget for the Compliance department.
• Committee Leadership: Chair the Compliance Committee and related sub-committees.
• Vendor Oversight: Coordinate the oversight activity of affiliated contractors and delegates.
• FWA Program: Enhance and maintain a Fraud, Waste, and Abuse (FWA) prevention, detection, and operational program.

• Education: Bachelor's degree required; JD, MBA, or Master's in Healthcare Administration preferred.
• Experience: Minimum of 8 years of experience in healthcare compliance, preferably within managed care or delegated service organizations.
• Regulatory Knowledge: Deep understanding of regulatory frameworks including CMS, HIPAA, and state Medicaid/Medicare regulations.
• Industry Domain: Experience working with delegated services and provider networks.
• Leadership: Proven ability to lead cross-functional teams and influence organizational change.
• Communication: Exceptional communication and presentation skills, with experience reporting to executive leadership and boards.
• Analytical Skills: Strong analytical and problem-solving skills.
• Certification in Healthcare Compliance (CHC) or similar credential.
• Experience with compliance technology platforms and data analytics