Compliance Manager - Remote

Rising Medical Solutions

5d•Remote

About The Position

The Compliance Manager supports Rising Medical Solutions’ corporate compliance program by ensuring adherence to federal, state, and industry regulatory requirements across managed care, bill review, utilization review, provider networks, and case management. This role oversees multi‑state managed care programs, including MPN, MCO, bill review, and timely pay compliance, and leads regulatory filings, renewals, reporting, and customer implementations. The Compliance Manager monitors legislative and regulatory developments impacting managed care and medical billing operations and serves as a key liaison with regulatory agencies, customers, and internal stakeholders. This position acts as a regulatory subject‑matter expert, supporting organizational compliance with state‑specific workers’ compensation laws, administrative rules, and accreditation standards while promoting operational integrity and effective communication.

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

Responsibilities

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