Compliance Manager

Role Overview

• Monitor and analyze state and federal regulatory developments, legislation, and industry trends governing workers compensation affecting Rising’s lines of business
• Independently research, track, and assess regulatory impact on managed care, bill review, and timely pay operations
• Communicate regulatory changes to internal teams and customers
• Provide input and subject matter expertise in the development of corporate compliance training materials.
• Support clinical operations to maintain and support URAC certification and reaccreditation.
• Manage certified managed care programs (MPN/MCO), including state filings, renewals, amendments, and reporting
• Serve as primary contact with state regulatory agencies regarding filings, audits, deficiencies, and inquiries
• Lead implementation and rollout of customer managed care programs
• Maintain historical archives and resource documentation for state filings and customer materials.
• Provide support for state UR certification processes, including renewals and compliance monitoring, and URAC certification
• Develop and maintain managed care resource materials for Rising state filings and customer worksite materials
• Oversee the coordination of resources to ensure the ongoing effectiveness of the state managed care programs
• Monitor state regulatory sources for provider suspensions, exclusions, arrests, and fraud‑related actions affecting workers’ compensation participation
• Direct validation of provider TIN/NPI data, ensure fraud flags are entered in Vision, and oversee timely alerts to bill review and utilization review teams when exposure is identified
• Lead and manage the MPN Coordinator team, ensuring consistent application of MPN rules, compliance standards, and service expectations
• Oversee provider compliance, including credentialing changes, suspensions, fraud monitoring, and continuity of care
• Monitor workload distribution and completion of MPN scheduling tasks to ensure service level expectations are met
• Provide coaching and performance oversight to support timely, accurate responses to MPN requests from injured workers, customers, adjusters, and attorneys
• Review geo‑access analysis and direct corrective actions to address network coverage gaps; serve as escalation point and backup responder as needed
• Maintain regulatory documentation, dashboards, trackers, and compliance materials
• Support RFP responses related to managed care, bill review, timely pay, and regulatory compliance
• Manage cross-functional projects through planning, research, implementation, and audit review
• Support maintenance of Business Continuity Plans and Disaster Recovery Plan and ensure their updates

Requirements

• Bachelor' s degree in business administration or related field and ten (10) years significant business experience, or ten (10) years of industry experience
• Significant experience in research and interpretation of Workers' Compensation state managed care plans and medical bill review requirements
• Proven ability to manage multiple projects and deadlines in a regulated environment
• Experience working with regulatory agencies, customers, and internal operational teams
• Ability to interpret legislation and translate regulatory requirements into operational guidance
• Excellent attention-to-detail, planning, and follow-through skills
• Critical thinking and problem-solving skills
• Must be a self-starter, flexible, customer-focused, and have a professional demeanor
• Ability to work independently and as part of a team
• Knowledge of industry regulations, terminology, principles, and practices; familiarity with legal reference materials, and thorough understanding of research techniques
• Proficiency with Microsoft Office applications, SharePoint, Office 365
• Excellent oral and written communication skills
• Excellent organizational/time management skills
• Experience writing briefs and/or position papers

Benefits

• Health insurance (4 different plans to choose from)
• Dental
• Vision
• Paid time off (PTO) or Flexible Time Off (FTO)
• 401(k)
• Basic Life Insurance and Long-Term Disability Insurance (paid by the company)
• Voluntary Life Insurance and Short-Term Disability Insurance
• Flexible Spending Accounts (FSA)
• Employee Assistance Program (EAP)
• Rise Well Wellness Program
• Professional Development Reimbursement Program (PDRP)
• You will be part of our new Elevate program designed to recognize and reward employees for their hard work
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