Assistant Director Clinical Regulatory Operations

Cambia Health Solutions•Medford, OR

18d•$113,780 - $208,000•Hybrid

About The Position

The Assistant Director Clinical Regulatory Operations leads a clinical regulatory operations team within Cambia’s Transformation, Quality, and Learning team. The role is a strategic partner to Health Services Operations (HSO) clinical business leaders, helping advance affordability, operational efficiency, quality, and member experience while ensuring compliance with CMS, state, NCQA, privacy, and contractual requirements. The position works with regulatory stakeholders and clinical business owners to interpret evolving requirements, build scalable monitoring and remediation frameworks, and simplify and align processes across teams and lines of business. This people-leadership role oversees regulatory compliance operations across Utilization Management and Appeals, Care Management, Pharmacy, and Payment Integrity. It leads compliance programs, audits, monitoring, reporting, corrective action plans, NCQA accreditation readiness, the HSO Rapid Resolution Team, and the Clinical Review Inter-rater Reliability program. The role also manages staff, budgets, workforce allocation, projects, and long-term departmental goals. The position is hybrid, with three days per week in an office, at one of the listed Cambia locations.

Requirements

Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or a related field.
Five years of leadership experience.
Seven years of health insurance or managed care experience focused on regulatory compliance, quality management, or clinical operations, or an equivalent combination of education and experience.
Demonstrated knowledge of CMS, state, NCQA, HIPAA/privacy, and managed care contract compliance requirements as applied to Utilization Management and Appeals, Care Management, Pharmacy, and Payment Integrity.
Ability to interpret complex regulatory requirements and translate them into clear operational guidance for diverse audiences.
Competency in designing and executing compliance monitoring, auditing, and reporting programs in a health plan or managed care environment.
Knowledge and application of improvement science methodologies, such as PDSA, Lean, and Six Sigma, to drive operational improvement.
Ability to analyze and align processes across multiple teams and lines of business to achieve standardization, simplification, and scalability.
Experience leading cross-functional regulatory implementation efforts with clinical operations, legal, compliance, and regulatory affairs.
Ability to identify compliance gaps, conduct root cause analysis, and lead data-driven remediation across operational teams.
Experience leveraging automation, data analytics, and technology to improve compliance monitoring and program effectiveness.
Competency in resource and project management, including budgeting, workforce planning, and delivery management.
Ability to develop and lead teams across multiple locations or remote environments, including hiring, goal setting, coaching, and development.
Strong written and verbal communication skills, including regulatory memos, executive reporting, and presentations.
Experience writing policies and procedures and developing monitoring and auditing tools.

Nice To Haves

Master’s degree in Healthcare Administration, Nursing, Public Health, or a related field.
Familiarity with dashboard development or workflow automation.
Experience with AI tools and technologies to enhance productivity and decision-making.

Responsibilities

Partner with Regulatory Affairs, Quality, Legal, Compliance, and clinical business owners to interpret and operationalize evolving regulatory requirements across HSO program areas.
Serve as a strategic partner to HSO clinical leaders to support affordability, operational efficiency, quality, and member experience within regulatory requirements.
Compare and align processes across teams and lines of business, standardizing where appropriate to reduce redundancy and improve scalability.
Design, execute, and continuously improve regulatory compliance programs using improvement science methodologies, and evaluate program efficiency to streamline processes and optimize resources.
Establish and improve audit and monitoring processes, including automation, dashboards, real-time reporting, and data visualization in partnership with data, analytics, and technology teams.
Develop reporting frameworks that provide leadership with timely insights into compliance status, risk exposure, and program performance.
Manage corrective action plans arising from internal monitoring, external audits, and accreditation surveys; use root cause analysis to support sustainable remediation.
Identify emerging compliance trends and risk areas and recommend mitigation strategies; ensure legislative, regulatory, and accreditation changes are implemented within required timeframes.
Lead NCQA accreditation readiness activities, including gap assessments, mock audits, and submission preparation.
Oversee the HSO Rapid Resolution Team’s management of complex member escalation cases, including root cause analysis and trend monitoring.
Oversee the Clinical Review Inter-rater Reliability program, including calibration, statistically valid sampling, and performance benchmarks aligned with NCQA, URAC, and industry practices.
Manage staff performance reviews, development, hiring, coaching, and retention; lead a team of 30 FTEs.
Manage the department budget, authorize expenditures, monitor workforce allocation, and oversee project plans.
Establish long-term departmental goals with division leadership and act as liaison between HSO program areas and enterprise stakeholders.
Provide direction to the team, engage team members toward common goals, and foster a positive work experience.

Benefits

Medical, dental, and vision coverage for employees and eligible family members, including mental health benefits.
Annual employer contribution to a health savings account.
Paid time off and 10 company-paid holidays.
401(k) plan with a company match and a potential discretionary contribution based on company performance.
Up to 12 weeks of paid parental time off, subject to eligibility requirements.
Wellness programs.
Employee Assistance Fund.
Commute and parking benefits.
Competitive salary and bonus opportunities.
Employee resource groups and company-supported community outreach programs.