Senior Director, Regulatory Affairs – Delegated Services

Job not on LinkedIn

🔥 11 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $135k - $175k / year

⏰ Full Time

🟠 Senior

🚔 Compliance

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Dayforce

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

👥 HR Tech

☁️ SaaS

🏢 Enterprise

💰 $1G Post-IPO Debt - Dayforce on 2024-03

HR Tech • SaaS • Enterprise

Dayforce is a cloud-based human capital management (HCM) platform offered by Ceridian. Dayforce provides integrated HR, payroll, time and attendance, scheduling, benefits, talent management, and workforce analytics to help employers manage the entire employee lifecycle in a single application. It is delivered as a software-as-a-service product aimed at medium to large organizations and HR/people operations teams.

📋 Description

• Lead regulatory strategy, governance, and oversight for delegated services across Medicare, Medicaid, and Commercial lines of business, ensuring alignment with federal, state, payer, and contractual requirements. • Serve as the subject matter expert on full delegation requirements, including delegated utilization management, clinical decision-making oversight, denials, appeals, grievances, and related reporting obligations. • Own enterprise audit readiness for delegated UM functions, including CMS audits, health plan delegation audits, state regulatory reviews, mock audits, gap assessments, tracer development, documentation reviews, and remediation planning. • Lead development, execution, and monitoring of corrective action plans, ensuring root cause analysis, sustainable remediation, and ongoing performance monitoring. • Interpret and operationalize delegated contractual obligations and state-specific regulatory requirements, including utilization management rules, notice requirements, turnaround times, physician reviewer requirements, member protections, and delegation oversight expectations to ensure operational alignment, compliance governance, and audit defensibility. • Establish and maintain a state-by-state regulatory framework, including compliance matrices, workflow requirements, regulatory monitoring systems, and control structure to support multi-state delegated operations. • Develop regulatory risk escalation pathways, governance structures, and remediation strategies for identified compliance vulnerabilities across delegated operations. • Oversee physician licensing compliance for medical directors, peer reviewers, and other clinical staff performing delegated functions, ensuring appropriate state licensure, renewal tracking, exclusions monitoring, and compliance with state-specific reviewer requirements. • Ensure delegated services are structured to comply with federal, state, contractual, and accreditation standards, including coverage determination, appeal, grievance, timeliness, documentation, and oversight expectations. • Provide regulatory leadership for Medicaid delegated services, including interpretation of state-specific Medicaid and managed Medicaid requirements and coordination with plan-specific expectations. • Partner with operations and technology teams to assess, design, and improve technical workflows that support delegated denials, appeals, and grievances processes, including intake, case routing, escalation paths, notices, queue management, documentation, audit trails, and reporting. • Ensure delegated workflows support accurate decision-making, timely processing, complete documentation, and defensible audit outcomes. • Collaborate with legal, compliance, and business leaders on delegation-related contract language, oversight models, and risk mitigation strategies. • Monitor, interpret, and operationalize changes in CMS, state, and payer requirements, including enterprise impact assessment and translate those changes into policies, procedures, system requirements, and operational controls. • Monitor, interpret, and communicate emerging legislative, regulatory, and policy developments across federal, state, payer, and delegated environments, proactively assessing organizational impact and guide strategic readiness. • Support development and maintenance of policies and procedures aligned with applicable regulatory and accreditation standards, including CMS, NCQA, URAC, and payer-specific delegation standards. • Serve as a key point of contact with external health plan partners, auditors, regulators, and accreditation entities related to delegated compliance activities.

🎯 Requirements

• 10+ years of progressive leadership experience in healthcare regulatory affairs, delegated services oversight, compliance, or managed care operations. • Significant hands-on experience leading and managing audits, including CMS audits, payer delegation audits, and/or state regulatory reviews. • Proven success building and sustaining audit-ready delegated programs, including corrective action planning and remediation management. • Direct experience overseeing or partnering closely on denials, appeals, and grievances operations in a delegated or payer environment. • Experience with physician licensing compliance across multiple states, including oversight of licensure verification, renewals, and state-specific reviewer qualifications.