The Compliance Manager is responsible for policy development, coordinating and performing all pre-delegation and annual due diligence audits and monitoring of delegated activities to ensure compliance with National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), contractual agreements, and State and Federal requirements.

What you'll be doing:

• Develop and maintain all compliance policies associated with accreditations.

• Coordinate all facets of the URAC and NCQA accreditation and reaccreditation process including ensuring all activities, documentation and evidence necessary for the accreditation are prepared in compliance with accreditation standards.

• Assist in training in current NCQA and URAC standards as appropriate to job functions.

• Serve as a resource for other departments for developing compliant operational processes.

• Implement compliance programs, policies and procedures designed to ensure compliance with all applicable federal laws, regulations and delegation requirements.

• Analyze delegation audit results and makes recommendations for improvement.

• Identify and communicate with appropriate departments, teams, and key leadership on internal audit results and/ or deficiencies. * Prepares audit files for submission as required.

• Participate in delegation audits, supplying information as needed.

• Perform tasks related to external audits from contracted health plans/employer groups as well as pre-delegation review with potential health plans as required.

• Coordinate with delegated partners to ensure adherence to all regulations, contractual agreements, and guidelines.

• Follow up on corrective action plans ensuring timely closure.

• Prepare adverse determination notices in compliance with regulatory requirements.

• Demonstrate proficiency in the application of health plan/employer group guidelines and nationally recognized review criteria.

• Demonstrate a solid understanding of utilization management.

• Review and adhere to department policies and the Utilization Management plan.

• Conduct standard random audits and focused audits to determine compliance to departmental standards.

• Supervise the licensing and credentialing function to ensure requirements are met and maintained.

• Perform other duties as assigned.

About you:

• Clinical degree, Bachelor's or Master's degree in a related field

• Minimum of 10 years in healthcare legal operations, healthcare project management, internal audit or healthcare compliance

• Minimum of 8 years of compliance policy development, audit, and maintenance with a strength in NCQA, URAC, and HIPAA.

• Proven track record of working with external regulatory and compliance partners for client relationship management and consultation within healthcare.

• Excellent messaging, positioning, and presentation of policy to internal and external stakeholders

• Unparalleled project management skills - identify a goal and the steps needed; actively manage action steps to accomplish goal while managing and holding key stakeholders accountable.

• Strong compliance acumen; strong problem-solving, judgment and analytic skills.

• Prior experience and success in a fast-growing organization.