Director, Operations – Regulatory and Accuracy Assurance Oversight

🔥 2 minutes ago

🇺🇸 United States – Remote

💵 $113k - $197.7k / year

⏰ Full Time

🔴 Lead

⚙️ Operations

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Serve as the Operations liaison with enterprise Compliance, Regulatory, Legal, and Audit leaders for Claims, Configuration, Enrollment, Payment Integrity, Grievance & Appeals, Encounters, and Provider & Member Data • Represent Operations internally and externally with regulators and auditors • Coordinate responses, requests, audits, investigations, and remediation with enterprise partners • Interpret and implement laws, regulations, guidance, contracts, and related requirements • Lead Operations accuracy assurance through risk-based and independent auditing of operational outcomes and processes • Identify root causes, report findings and trends, and oversee corrective actions through sustainable resolution • Establish and advance automated auditing capabilities, including agentic approaches • Lead transformation of Operations teams and workflows to increase automation, accuracy, efficiency, and control effectiveness • Define measures of success and monitor realized outcomes • Monitor regulatory and legislative changes and coordinate communication and implementation across impacted Operations areas • Draft operational responses for state agencies, departments of insurance, and other regulators • Maintain integrated tracking and reporting for regulatory, compliance, audit, and accuracy assurance matters • Keep direct-line leadership and the Corporate Compliance Officer informed of material initiatives, concerns, risks, operational issues, and corrective actions • Provide Operations status reporting to the Corporate Compliance Officer and applicable committees • Build relationships with leaders and business partners to identify, prioritize, and mitigate operational and compliance risks • Perform other job-related duties as requested

🎯 Requirements

• Bachelor's degree in business or related field required • Equivalent years of relevant work experience may be accepted in lieu of required education • Five (5) years of healthcare operations experience, including three (3) years in Government Program products • Five (5) years of leadership experience • Experience leading operational accuracy assurance, quality auditing, control testing, or equivalent assurance activities • Experience transforming operational teams and processes through automation, workflow redesign, and measurable efficiency improvement • Advanced proficiency in Microsoft Word, Excel, and PowerPoint • Strong data analysis, trending, root-cause analysis, and performance measurement skills • Deep knowledge of healthcare operations concepts, practices, procedures, and accuracy-control frameworks • Understanding of compliance and regulatory requirements for managed care and government programs, including CMS, HHS, departments of insurance, and Medicaid agencies • Knowledge of automated auditing, continuous monitoring, artificial intelligence, and agentic solutions, including governance, testing, validation, and escalation controls • Demonstrated transformation leadership, including operating-model design, workflow automation, change management, and benefits realization • Strong strategic leadership, stakeholder management, negotiation, and decision-making skills • Excellent written and verbal communication skills • Ability to work independently and collaboratively, manage competing priorities and project timelines, and maintain strong attention to detail • Customer-focused critical thinking, listening, and problem-solving skills • Certified in Healthcare Compliance (CHC) preferred • Ability to travel as required by the needs of the business • Master's degree preferred • Experience applying automation and artificial intelligence to operational auditing or monitoring, including agentic use cases, governance, validation, human oversight, and sustained production performance preferred • Compliance oversight leadership experience within healthcare operations strongly preferred

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee total well-being investment • Equal opportunity and belonging-focused workplace