Provide on-going guidance to the business on claims and compliance-related matters.
Act as the primary SME for compliance matters related to claims administration, FWA and billing standards.
Develop and oversee the internal auditing and monitoring programs to proactively identify risks.
Oversee the response and strategy for client-driven external audits and regulatory inquiries.
Collaborate with the Compliance team to create and implement the Annual Risk Assessment and Compliance Work Plan.
Support the development and refinement of compliance policies that align with industry benchmarks.
Establish and maintain a robust compliance reporting program.
Prepare detailed reports and updates for the Compliance Officer to share with the Board of Directors and management.
Bridge gap between healthcare claims adjudication workflows, product design and data engineering.

Minimum of 15 years in healthcare compliance, specifically within a TPA or Health Plan.
At least 5 years of experience supervising compliance teams with a focus on coaching and professional development.
Proven track record of designing and performing complex compliance audits and investigations.
Deep understanding of U.S. healthcare regulations, claims adjudication, and billing standards.
Ability to explain the 'how' and 'why' of compliance programs to diverse stakeholders and build strong cross-departmental relationships.
Bachelor’s degree required; Masters or Juris Doctorate strongly preferred. CHC certification (or eligibility) is required. RHIA, RHIT, CCS, CPC, CPB, COC, CIC strongly preferred.

Director, Compliance Programs

Key skills