Senior Compliance Advisor, State Health Plan(SHP)

Blue Shield of North Carolina•Durham, NC

About The Position

The Senior Compliance Advisor, State Health Plan (SHP), leads the day-to-day activities required 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. The advisor identifies compliance risks, interprets and operationalizes requirements, develops or facilitates corrective action plans, and conducts audits and compliance reviews to monitor adherence to NCQA standards, North Carolina Department of Insurance requirements, ERISA, MHPAEA, contractual obligations, and applicable federal and state laws and regulations. The advisor applies healthcare compliance expertise to complex enterprise-wide 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 partners with business and clinical stakeholders, evaluates parity compliance, supports regulatory and accreditation reviews, develops training and communications, and provides technical guidance to less experienced team members.

Requirements

Bachelor's degree or advanced degree where required; in lieu of a degree, 7+ years of experience in a related field.
5+ years of experience in a related field.
Deep healthcare compliance and regulatory expertise.
Ability to interpret and operationalize applicable requirements and develop or facilitate corrective action plans.
Experience or expertise addressing Case Management and Utilization Management, including medical necessity review, care coordination, appeals, grievances, member protections, and delegated functions.
Ability to research and interpret NCQA standards, North Carolina Department of Insurance requirements, ERISA, MHPAEA, plan documents, contracts, and other federal and state laws.
Strong judgment, analytical skills, influence, and cross-functional leadership; ability to manage multiple high-risk priorities in a complex healthcare environment.

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.

Responsibilities

Apply healthcare compliance and regulatory expertise to resolve complex, enterprise-wide 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 accreditation requirements, plan documents, and contracts; translate them into operational guidance, policies, controls, and implementation plans.
Advise business leaders on compliance implications and recommend practical solutions that account for regulatory obligations, clinical integrity, member experience, and operational needs.
Partner with SHP leadership, Legal, Clinical, Case Management, Utilization Management, Behavioral Health, Appeals and Grievances, Network, Benefits, Operations, Vendor Management, and other stakeholders to resolve cross-functional 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 validate corrective and preventive actions.
Assist with initiating internal quality improvement plans based on audit findings, including root cause analysis, targeted training, remediation, and progress tracking with the Education team.
Evaluate MHPAEA and parity compliance across physical and behavioral health programs, including financial requirements, quantitative and nonquantitative treatment limitations, and related access, timeliness, notice, and member communication requirements.
Support SHP readiness for NCQA surveys and other regulatory or accreditation reviews through evidence collection, gap assessment, interview preparation, and remediation tracking.
Lead analysis of 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 to promote consistent execution of compliance requirements.
Review policies, procedures, workflows, clinical documents, contracts, benefit booklets, plan documents, and marketing and member-facing materials for compliance; provide actionable feedback and support development as needed.
Provide coaching and technical guidance to less experienced team members and may coordinate work across compliance initiatives.