Sr. Compliance Specialist - Care Management Programs

Valenz • Phoenix, AZ

4d • Remote

About The Position

As a Sr. Compliance Specialist - Care Management Programs (aka Sr. Product Compliance Specialist - Care), you'll partner with Care Management and Utilization Management teams as the primary compliance resource for regulatory, accreditation, and licensing requirements impacting clinical operations. You'll provide risk-based compliance oversight for areas including CMS regulations, NCQA and URAC standards, multi-state UM licensing requirements, regulatory change management, and other operational initiatives. You'll work closely with Product, Operations, and Corporate Compliance teams to support policy governance, compliance training, issue intake management, and ongoing efforts to ensure compliance with applicable regulatory and accreditation requirements.

Requirements

• Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or a related field.
• 5+ years of experience in healthcare compliance, regulatory affairs, clinical operations, or a related healthcare environment.
• Demonstrated experience supporting Utilization Management, Care Management, and/or Disease Management programs.
• Working knowledge of CMS regulatory frameworks and managed care compliance requirements.
• Experience with NCQA and/or URAC accreditation standards and related operational readiness activities.
• Strong understanding of multi-state healthcare regulatory and compliance environments.

Nice To Haves

• Experience managing or supporting multi-state Utilization Management licensure programs.
• Clinical background, such as Registered Nurse (RN) or equivalent clinical experience.
• Knowledge of 42 CFR Part 2 requirements and related privacy regulations.
• Experience operating within a Business Associate environment.
• Relevant professional certification preferred, such as Certified in Healthcare Compliance (CHC), Certified Professional in Healthcare Quality (CPHQ), or equivalent.

Responsibilities

• Serve as the primary compliance liaison for Care Management and Utilization Management operations, providing strategic guidance and oversight to ensure adherence to applicable regulatory and accreditation requirements.
• Interpret, assess, and operationalize regulatory standards, including CMS Medicare Advantage and Managed Care requirements, NCQA and URAC accreditation standards, Utilization Review and Utilization Management regulations, and 42 CFR Part 2 requirements, as applicable.
• Oversee and support the organization’s multi-state Utilization Management licensing program by tracking licensing requirements across applicable jurisdictions, coordinating license applications and renewals, maintaining supporting documentation, and partnering with operational leaders to ensure ongoing compliance with licensing conditions and regulatory obligations.
• Provide compliance guidance and subject matter expertise related to clinical workflows, operational processes, policy development, and system implementations impacting Care operations.
• Support the full lifecycle management of Care-related policies, standard operating procedures, and associated documentation.
• Monitor regulatory developments and emerging compliance requirements, evaluate operational impact, and communicate relevant updates and recommendations to key stakeholders.
• Participate in high-risk initiatives, operational enhancements, and product or process changes to ensure compliance considerations are appropriately addressed.
• Support organizational readiness for audits, regulatory reviews, and accreditation activities, including NCQA and URAC surveys.
• Assist with incident response activities involving Care operations, including privacy-related inquiries, compliance investigations, and regulatory escalations.
• Collaborate with Corporate Compliance and cross-functional teams on issue intake, triage, tracking, remediation, and resolution efforts.
• Provide education, training, and ongoing guidance to internal stakeholders regarding applicable regulatory and compliance requirements.
• Maintain accurate and organized documentation to support compliance activities, regulatory inquiries, audits, and accreditation requirements.

Benefits

• Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card.
• Spending account options: HSA, FSA, and DCFSA
• 401K with company match and immediate vesting
• Flexible working environment
• Generous Paid Time Off to include vacation, sick leave, and paid holidays
• Employee Assistance Program that includes professional counseling, referrals, and additional services
• Paid maternity and paternity leave
• Pet insurance
• Employee discounts on phone plans, car rentals and computers
• Community giveback opportunities, including paid time off for philanthropic endeavors

What This Job Offers

• Job Type: Full-time
• Career Level: Senior