Senior Compliance Specialist – Care Management Programs

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🕒 Junho 6

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Vālenz® Health

SiteLinkedInTodas as Vagas

501 - 1000 funcionários

Fundada em 2004

⚕️ Seguro de Saúde

💳 Fintech

☁️ SaaS

Healthcare Insurance • Fintech • SaaS

A Vālenz® Health é uma provedora de soluções abrangentes para planos de saúde que oferece uma plataforma totalmente integrada, projetada para simplificar as complexidades do setor de saúde para empregadores, pagadores, provedores e membros. A empresa foca em aumentar a qualidade e reduzir custos por meio de insights baseados em dados, navegação para membros, redes de provedores e gestão robusta de sinistros. Ao conectar diversos stakeholders no ecossistema de saúde, a Vālenz busca melhorar os resultados de saúde e otimizar a experiência de saúde para todos os envolvidos.

Descrição

• Serve as the primary compliance liaison for Care Management and Utilization Management operations, providing strategic guidance and oversight to ensure adherence to applicable regulatory and accreditation requirements • Interpret, assess, and operationalize regulatory standards, including CMS Medicare Advantage and Managed Care requirements, NCQA and URAC accreditation standards, Utilization Review and Utilization Management regulations, and 42 CFR Part 2 requirements, as applicable • Oversee and support the organization’s multi-state Utilization Management licensing program by tracking licensing requirements across applicable jurisdictions, coordinating license applications and renewals, maintaining supporting documentation, and partnering with operational leaders to ensure ongoing compliance with licensing conditions and regulatory obligations • Provide compliance guidance and subject matter expertise related to clinical workflows, operational processes, policy development, and system implementations impacting Care operations • Support the full lifecycle management of Care-related policies, standard operating procedures, and associated documentation • Monitor regulatory developments and emerging compliance requirements, evaluate operational impact, and communicate relevant updates and recommendations to key stakeholders • Participate in high-risk initiatives, operational enhancements, and product or process changes to ensure compliance considerations are appropriately addressed • Support organizational readiness for audits, regulatory reviews, and accreditation activities, including NCQA and URAC surveys • Assist with incident response activities involving Care operations, including privacy-related inquiries, compliance investigations, and regulatory escalations • Collaborate with Corporate Compliance and cross-functional teams on issue intake, triage, tracking, remediation, and resolution efforts • Provide education, training, and ongoing guidance to internal stakeholders regarding applicable regulatory and compliance requirements • Maintain accurate and organized documentation to support compliance activities, regulatory inquiries, audits, and accreditation requirements

🎯 Requisitos

• Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or a related field • 5+ years of experience in healthcare compliance, regulatory affairs, clinical operations, or a related healthcare environment • Demonstrated experience supporting Utilization Management, Care Management, and/or Disease Management programs • Working knowledge of CMS regulatory frameworks and managed care compliance requirements • Experience with NCQA and/or URAC accreditation standards and related operational readiness activities • Strong understanding of multi-state healthcare regulatory and compliance environments • A plus if you have… • Experience managing or supporting multi-state Utilization Management licensure programs • Clinical background, such as Registered Nurse (RN) or equivalent clinical experience • Knowledge of 42 CFR Part 2 requirements and related privacy regulations • Experience operating within a Business Associate environment • Relevant professional certification preferred, such as Certified in Healthcare Compliance (CHC), Certified Professional in Healthcare Quality (CPHQ), or equivalent.

🏖️ Benefícios

• Competitive benefits package with generous employer subsidies • Flexible and remote working options • 401k with generous employer match and immediate vesting • Personal and professional development opportunities • Supportive family benefits, including paid leave for new family members • Companywide philanthropic program, Valenz Communities Connection