Sr. Compliance Specialist - Care Management Programs (Healthcare)

TL;DR

Sr. Compliance Specialist - Care Management Programs (Healthcare Compliance): Overseeing regulatory, accreditation, and licensing requirements for clinical operations with an accent on CMS regulations, NCQA, and URAC standards. Focus on operationalizing regulatory standards, managing multi-state UM licensing, and ensuring organizational readiness for audits.

Location: Remote (Must be US based)

Company

A healthcare platform that simplifies the experience for employers, payers, and providers to reduce costs and improve quality.

What you will do

• Serve as the primary compliance liaison for Care and Utilization Management operations, providing strategic guidance.
• Interpret and operationalize regulatory standards, including CMS, NCQA, URAC, and 42 CFR Part 2.
• Oversee the multi-state Utilization Management licensing program, coordinating applications and renewals.
• Provide expertise on clinical workflows, operational processes, and system implementations impacting Care operations.
• Monitor regulatory developments and evaluate their operational impact for key stakeholders.
• Support organizational readiness for audits, regulatory reviews, and accreditation surveys.

Requirements

• Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or a related field.
• 5+ years of experience in healthcare compliance, regulatory affairs, or clinical operations.
• 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.
• Must be US based to comply with company policies and HIPAA.

Nice to have

• Experience managing multi-state Utilization Management licensure programs.
• Clinical background, such as a Registered Nurse (RN).
• Knowledge of 42 CFR Part 2 requirements and privacy regulations.
• Professional certifications such as CHC or CPHQ.

Culture & Benefits

• Subsidized Medical, Dental, and Vision insurance.
• Spending account options: HSA, FSA, and DCFSA.
• 401K with company match and immediate vesting.
• Generous Paid Time Off, including vacation, sick leave, and paid holidays.
• Paid maternity and paternity leave.
• Flexible working environment and pet insurance.