Regulatory Compliance Manager (Hybrid)

CareFirst•Baltimore, MD

3d•Hybrid

About The Position

This role is directly accountable for establishing, managing, and monitoring compliance processes for government programs, with a focus on Complaint Tracking Module (CTM) process management, vendor compliance & oversight, and operational compliance. The manager works with leadership, business owners, Corporate Compliance, Legal, Mandates, and delegated entities to ensure Medicare complaints, vendor activities, policies, procedures, workflows, and monitoring activities remain aligned with CMS requirements, Federal and State regulations, contractual obligations, and the Corporate Compliance framework. The position identifies and mitigates regulatory risk, supports audit readiness, drives systemic improvements, and promotes timely, accurate, and compliant outcomes that improve the member experience.

Requirements

Bachelor's Degree in Healthcare Compliance, Risk Management, Business Administration or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
5 years experience in health insurance industry, managed care and government programs, health insurance compliance programs, CTM or complaint operations, vendor & delegated entity compliance and oversight, or related fields.
1 year supervisory experience or demonstrated progressive leadership experience.
Must be eligible to work in the U.S. without Sponsorship.

Nice To Haves

Experience with CMS Medicare Advantage requirements, CTM process management, complaint handling, First Tier, Downstream, and related entity oversight, vendor management compliance, monitoring, auditing, and corrective action management.
Excellent interpersonal skills with ability to build consensus and agreement and bring resolution to contentious issues and entrenched interests.
Ability to research complex issues, interpret CMS Medicare Advantage regulations and regulatory guidance, apply sound judgment to CTM process management, complaint handling, vendor and delegated entity compliance and oversight, and operational compliance matters.
Demonstrated ability to lead problem-solving discussions.
Strong organizational, coordination, reporting, and interpersonal skills for facilitating compliance audits, CTM oversight, vendor management compliance, and cross-functional issue resolution.

Responsibilities

Leads end-to-end CTM process management to support timely complaint assignment, resolution, documentation, trend identification, and escalation of regulatory risk.
Partners with operational teams to strengthen complaint outcomes, reduce repeat issues, improve process controls, and ensure CTM activities are consistently executed and monitored in accordance with CMS expectations and internal compliance standards.
Oversees vendor management compliance for First Tier, Downstream, and related entities and delegated entities supporting Medicaid programs, including contractual and regulatory performance monitoring, issue escalation, corrective action tracking, and communication of compliance expectations.
Works with vendors, delegated entities, and internal business owners to promote timely, accurate, and compliant performance.
Provides interpretation of regulations, regulatory guidance, and CMS expectations related to CTM, complaint handling, vendor oversight, and operational compliance.
Partners with business areas, Legal, Mandates, Corporate Compliance, and delegated entities to ensure policies, procedures, SOPs, workflows, systems, and monitoring activities remain current and compliant.
Develops and manages risk-based monitoring, auditing, and control activities to test compliance with CTM, vendor, and operational requirements.
Reviews findings with stakeholders, supports response to internal and external audits, identifies root causes, and works with business owners to implement corrective actions and sustained process improvements.
Prepares, analyzes, and presents CTM, vendor compliance, audit, and risk reports to leadership, compliance committees, and operational stakeholders.
Identifies trends, systemic issues, and emerging risks and recommends actions to improve compliance performance, operational efficiency, and member experience.
Leads associate performance, training, and development activities to support effective CTM process management, vendor oversight, audit readiness, and regulatory compliance.
Creates and discusses performance plans and reviews, identifies development needs, and ensures staff adhere to policies, procedures, and established compliance processes.