Senior Compliance Advisor, State Health Plan(SHP)

Blue Cross and Blue Shield of North Carolina•Durham, CA

4d•$81,068 - $129,708

About The Position

The Senior Compliance Advisor, State Health Plan (SHP), leads day-to-day activities to maintain an effective compliance program for SHP operations and health plan administration. The role coordinates complex, cross-functional matters involving physical and behavioral health benefits, Case Management, Utilization Management, delegated entities, vendors, and clinical operations. It identifies compliance risks, interprets and operationalizes applicable requirements, develops or facilitates corrective action plans, and conducts audits and compliance reviews. The position monitors adherence to NCQA standards, North Carolina Department of Insurance requirements, ERISA, MHPAEA, contractual obligations, and other applicable federal and state laws and regulations. The advisor independently resolves complex enterprise-wide compliance questions, serves as a subject matter expert for physical and behavioral health Case Management and Utilization Management, and translates changing requirements into operational guidance, policies, controls, and implementation plans. The role advises leaders, partners across business and clinical functions, assesses risks and corrective actions, supports quality improvement plans and regulatory readiness, and evaluates MHPAEA and parity compliance. It also develops compliance training and communications, reviews policies and other materials, and provides technical guidance to less experienced team members.

Requirements

Bachelor's degree or advanced degree where required.
At least 5 years of experience in a related field.
In lieu of a degree, at least 7 years of experience in a related field.

Nice To Haves

Substantial experience in healthcare compliance, health plan operations, clinical operations, regulatory affairs, accreditation, or a related field.
Demonstrated understanding of Case Management and Utilization Management roles, responsibilities, workflows, documentation, and regulatory requirements across physical and behavioral health.
Working knowledge of NCQA accreditation standards, North Carolina Department of Insurance requirements, ERISA, MHPAEA and related behavioral health parity requirements, including comparative analyses of nonquantitative treatment limitations, and other federal and state requirements applicable to SHP.
Experience assessing delegated entities, vendors, or clinical programs and translating regulatory requirements into sustainable operational controls.
Ability to evaluate complex issues through clinical, regulatory, operational, and member-impact lenses and communicate recommendations to executive and operational audiences.
Strong judgment, analytical skills, influence, and cross-functional leadership, with the ability to manage multiple high-risk priorities in a complex healthcare environment.

Responsibilities

Independently resolve complex, enterprise-wide compliance questions affecting SHP benefits, operations, clinical programs, and vendor relationships.
Serve as a compliance subject matter expert for physical and behavioral health Case Management and Utilization Management, including medical necessity review, care coordination, appeals, grievances, member protections, and delegated functions.
Research and interpret regulatory and contractual requirements and translate them into operational guidance, policies, controls, and implementation plans.
Advise business leaders on compliance implications and recommend practical solutions that balance regulatory obligations, clinical integrity, member experience, and operational needs.
Partner with SHP leadership and cross-functional stakeholders to resolve compliance matters.
Conduct risk assessments, audits, and compliance reviews of business processes, clinical programs, systems, vendors, and delegated entities.
Monitor compliance metrics and emerging risks, and confirm corrective and preventive actions are implemented, sustained, and validated.
Assist with initiating internal quality improvement plans based on audit findings, including root cause analysis, targeted training, remediation, and progress tracking.
Evaluate MHPAEA and parity compliance across physical and behavioral health programs, including financial requirements, quantitative and nonquantitative treatment limitations, access, timeliness, notices, and member communications.
Support SHP readiness for NCQA surveys and other regulatory or accreditation reviews through evidence collection, gap assessment, interview preparation, and remediation tracking.
Analyze the enterprise and SHP regulatory environment and recommend compliance programming, monitoring, governance, and risk mitigation initiatives.
Develop training, tools, and communications for employees, leaders, vendors, and delegated entities.
Review policies, procedures, workflows, clinical documents, contracts, benefit booklets, plan documents, and marketing and member-facing materials for compliance, providing actionable feedback and supporting development as needed.
Provide coaching and technical guidance to less experienced team members and coordinate work across compliance initiatives as needed.