Director of Value Based Care Regulatory Compliance
$153,000–$191,300 year
RemoteUnited States
Job Summary
Lead markets compliance for Medicare Advantage and ACO programs, including ACO LEAD, ACO REACH, and MSSP regulatory and operational requirements, ensuring compliant program design and execution. Develop policies, procedures, and training specific to program operations while serving as the primary compliance liaison to physician partner groups and market leadership. Oversee coordination with health plans on audit activity and corrective actions, monitor CMS risk adjustment policy developments, and identify compliance gaps across enterprise operations. Collaborate with Legal to confirm ACO compliance obligations are met and assess the regulatory standing of clinical pathway vendors. Develop and present compliance metrics and reports for senior leadership and the internal Compliance Committee.
Required Qualifications
- Bachelor's degree in healthcare, business or related field
- 7+ years healthcare compliance experience with significant focus on risk adjustment, regulatory affairs, or managed care compliance
- 5+ years compliance auditing and monitoring experience, including audit program management and team oversight
- 5+ years supervisory experience managing compliance professionals
- Substantial experience with CMS program requirements across Medicare Advantage risk adjustment and ACO programs
- Experience at a health plan, health system, provider group or ACO
- Background in managed care operation, risk-based contracting or Medicare Advantage compliance
- Deep knowledge of OIG compliance requirements for MCOs, FDRs, and ACO participants, including audit expectations and high-risk condition monitoring
- Expertise with risk adjustment coding, RADV audit processes and supplemental data validation
- Skilled in regulatory change management, including monitoring, analyzing and communicating CMS and OIG guidance and updates
- Strong capability with preparing and delivering board and senior leadership level compliance metrics and reports
- Knowledge of value-based care, Medicare Advantage, fraud and abuse laws, and ACO REACH and MSSP programs
- Demonstrated leadership, sound independent judgment and the ability to operate effectively in a matrixed organization
- Strong written and verbal communication skills to advise multiple internal clients and external partners in a fast-paced, high-growth environment
- Ability to apply legal reasoning and sound judgment to complex, novel regulatory and transactional problems with incomplete information
- Ability to create and maintain documents using Microsoft Office (Word, Excel, Outlook, PowerPoint)
Desired Qualifications
- Master's degree preferred
- CHC preferred
- CPC or equivalent risk adjustment coding credential a plus
- Experience at a health plan, health system, provider group or ACO strongly preferred
- Background in managed care operation, risk-based contracting or Medicare Advantage compliance preferred
- Familiarity with CLM, matter management, or legal operations platforms preferred
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