Director, Operations Regulatory Oversight

Job Summary:

The Director, Operations Regulatory Oversight is responsible for representation and leadership of all regulatory and compliance activity on behalf of the Operations division. This Sr. Level leader serves as liaison to and works in collaboration with the enterprise Regulatory and the CareSource Compliance program on all Operations issues, risks, and preventative activity.

Essential Functions:

• Liaison with all internal area leaders Enterprise wide for compliance, regulatory, and audit functions on behalf of Claims, Configuration, Enrollment, Payment Integrity, Grievance & Appeals, Encounters, and Provider & Member data
• Collaborate with Operations leaders to proficiently represent Operations both internally and externally to Regulators and Auditors as appropriate for all audit, regulatory, and compliance issues in coordination with Compliance and/or Audit Departments. 
• Work with impacted operational business areas, Regulatory, and Legal to help ensure proper interpretation and implementation of such laws, regulations, guidance, contracts and similar regulatory requirements as identified by Market Regulatory and Corporate Compliance
• Maintain compliance, audit, and regulatory tracking and monitor issues through completion
• Monitor and review regulatory and legislative requirements and changes; respond to requests, audits, and investigations, communicate and implement regulatory requirements, and follow-up with appropriate areas to ensure required changes are effectively implemented
• Draft initial operational responses to the state, department of insurance and other regulatory agencies including internal stakeholders in a prudent layperson language so as to support easy understanding of the content and in a timely manner
• Ensure direct line leadership and the Corporate Compliance Officer are informed of all material regulatory initiatives, compliance concerns, operational issues and associated corrective actions/remediation impacting CareSource
• Accountable for Operations status reporting to Corporate Compliance Officer/Committee
• Maintains strong relationships with key leaders and business partners to identify and address compliance risks and manage action plans designed to fully mitigate compliance risk(s).
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree in business or related field or equivalent years of relevant work experience is required
• Master’s degree is preferred
• Minimum of five (5) years of healthcare operations experience including three (3) years in Government Program products is required
• Minimum of five (5) years of leadership experience is required
• Compliance oversight leadership experience within healthcare operations strongly preferred

Competencies, Knowledge and Skills:

• Advanced level experience in Microsoft Word, Excel and PowerPoint
• Data analysis and trending skills
• Familiarity with Healthcare operations concepts, practices and procedures
• Staffing and forecasting experience preferred
• Demonstrated understanding of Compliance and Regulatory fundamentals specifically related to managed care and government programs (CMS/HHS/DOI/Medicaid)
• Demonstrated professional communication skills, to include proper grammar usage, document structure, and business writing to audiences including but not limited to internal Leadership at all levels, internal and external Legal Counsel, Corporate Compliance, State and Federal Regulators
• Strategic management and leadership skills
• Ability to work independently and within a team environment
• Attention to detail
• Critical listening and thinking skills
• Negotiation skills/experience
• Time management skills including creation and maintenance of project timelines
• Customer service oriented
• Decision making/problem solving skills

Licensure and Certification:

• Certified in Healthcare Compliance (CHC) preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Some travel may be required

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.