Director, Operations – Regulatory and Accuracy Assurance Oversight

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as the Operations representative in collaboration with enterprise Compliance, Regulatory, Legal, and Audit leaders for Claims, Configuration, Enrollment, Payment Integrity, Grievance & Appeals, Encounters, as well as Provider & Member Data.

• Represent Operations in both internal and external interactions with regulatory bodies and auditors.

• Manage responses, requests, audits, investigations, and remediation efforts alongside enterprise partners.

• Interpret and apply laws, regulations, guidance, contracts, and related obligations.

• Drive accuracy assurance within Operations through risk-based and independent auditing of operational outcomes and processes.

• Identify root causes, document findings and trends, and supervise corrective actions to ensure sustainable resolution.

• Develop and enhance automated auditing capabilities, incorporating agentic approaches.

• Spearhead the transformation of Operations teams and workflows to enhance automation, accuracy, efficiency, and control effectiveness.

• Establish success metrics and track realized outcomes.

• Keep abreast of regulatory and legislative changes, coordinating communication and implementation within affected Operations areas.

• Prepare operational responses for state agencies, insurance departments, and other regulatory bodies.

• Maintain comprehensive tracking and reporting for regulatory, compliance, audit, and accuracy assurance issues.

• Keep direct-line leadership and the Corporate Compliance Officer updated on significant initiatives, concerns, risks, operational challenges, and corrective measures.

• Provide Operations status updates to the Corporate Compliance Officer and relevant committees.

• Cultivate relationships with leaders and business partners to identify, prioritize, and mitigate operational and compliance risks.

• Carry out additional job-related tasks as assigned.

⛳️ Requirements

• A bachelor's degree in business or a related field is required.

• Equivalent years of relevant work experience may be considered in place of the required education.

• A minimum of five (5) years of experience in healthcare operations, including three (3) years focused on Government Program products.

• At least five (5) years of leadership experience.

• Proven experience leading operational accuracy assurance, quality auditing, control testing, or similar assurance activities.

• Experience in transforming operational teams and processes through automation, workflow redesign, and measurable efficiency enhancements.

• Advanced skills in Microsoft Word, Excel, and PowerPoint.

• Strong abilities in data analysis, trending, root-cause analysis, and performance measurement.

• In-depth understanding of healthcare operations concepts, practices, procedures, and accuracy-control frameworks.

• Familiarity with compliance and regulatory requirements for managed care and government programs, including CMS, HHS, insurance departments, and Medicaid agencies.

• Knowledge of automated auditing, continuous monitoring, artificial intelligence, and agentic solutions, such as governance, testing, validation, and escalation controls.

• Demonstrated leadership in transformation, including operating-model design, workflow automation, change management, and benefits realization.

• Strong strategic leadership, stakeholder management, negotiation, and decision-making capabilities.

• Excellent written and verbal communication skills.

• Ability to work independently and collaboratively, manage competing priorities and project deadlines, while maintaining a keen attention to detail.

• Customer-focused critical thinking, listening, and problem-solving abilities.

• Certification in Healthcare Compliance (CHC) is preferred.

• Willingness to travel as required by business needs.

• A master's degree is preferred.

• Experience in applying automation and artificial intelligence within operational auditing or monitoring, including agentic use cases, governance, validation, human oversight, and sustained production performance, is preferred.

• Experience in compliance oversight leadership within healthcare operations is highly preferred.

🏝️ Benefits

• Bonus opportunities linked to both company and individual performance may be available.

• A comprehensive total rewards package is provided.

• Investment in employee total well-being.

• An equal opportunity and belonging-focused workplace.