Senior Director, Regulatory Affairs – Delegated Services

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

📋 Description

• Spearhead regulatory strategy, governance, and oversight for delegated services spanning Medicare, Medicaid, and Commercial business lines, ensuring adherence to federal, state, payer, and contractual obligations.

• Act as the subject matter authority on comprehensive delegation requirements, which encompass delegated utilization management, clinical decision-making oversight, denials, appeals, grievances, and associated reporting responsibilities.

• Take ownership of enterprise audit preparedness for delegated UM functions, encompassing CMS audits, health plan delegation audits, state regulatory evaluations, mock audits, gap analyses, tracer development, documentation assessments, and remediation strategies.

• Direct the formulation, execution, and monitoring of corrective action plans, ensuring thorough root cause analysis, sustainable remediation efforts, and continuous performance oversight.

• Analyze and operationalize delegated contractual commitments and state-specific regulatory criteria, including utilization management regulations, notification requirements, turnaround times, physician reviewer standards, member protections, and delegation oversight expectations to ensure operational consistency, governance compliance, and audit defensibility.

• Establish and uphold a regulatory framework by state, including compliance matrices, workflow prerequisites, regulatory monitoring systems, and control structures to facilitate multi-state delegated operations.

• Create pathways for regulatory risk escalation, governance frameworks, and remediation plans for identified compliance gaps within delegated operations.

• Supervise physician licensing adherence for medical directors, peer reviewers, and other clinical staff executing delegated functions, ensuring proper state licensure, renewal tracking, exclusions monitoring, and compliance with state-specific reviewer stipulations.

• Ensure that delegated services are organized to meet federal, state, contractual, and accreditation benchmarks, including coverage determinations, appeals, grievances, timeliness, documentation, and oversight expectations.

• Provide regulatory guidance for Medicaid delegated services, including the interpretation of state-specific Medicaid and managed Medicaid prerequisites and collaboration with plan-specific expectations.

• Collaborate with operations and technology teams to evaluate, design, and enhance technical workflows that support delegated denials, appeals, and grievances processes, including intake, case routing, escalation pathways, notifications, queue management, documentation, audit trails, and reporting.

• Ensure that delegated workflows facilitate precise decision-making, prompt processing, comprehensive documentation, and defensible audit results.

• Partner with legal, compliance, and business leaders to address delegation-related contract language, oversight frameworks, and risk mitigation tactics.

• Monitor, interpret, and implement changes in CMS, state, and payer stipulations, including enterprise impact assessments, translating those alterations into policies, procedures, system specifications, and operational controls.

• Track, interpret, and relay emerging legislative, regulatory, and policy trends across federal, state, payer, and delegated arenas, proactively evaluating organizational effects and guiding strategic preparedness.

• Assist in the creation and upkeep of policies and procedures aligned with relevant regulatory and accreditation standards, including CMS, NCQA, URAC, and payer-specific delegation benchmarks.

• Serve as a primary point of contact for external health plan partners, auditors, regulators, and accreditation bodies concerning delegated compliance initiatives.

⛳️ Requirements

• Over 10 years of progressive leadership experience in healthcare regulatory affairs, oversight of delegated services, compliance, or managed care operations.

• Extensive hands-on experience in leading and managing audits, including CMS audits, payer delegation audits, and/or state regulatory evaluations.

• Demonstrated success in establishing and maintaining audit-ready delegated programs, including corrective action planning and remediation oversight.

• Direct experience in supervising or closely collaborating on denials, appeals, and grievances operations in a delegated or payer context.

• Experience with physician licensing compliance across multiple states, including oversight of licensure verification, renewals, and state-specific reviewer qualifications.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health, dental, and vision insurance.

• Retirement savings plan with employer matching.

• Generous paid time off and holiday schedule.

• Opportunities for professional development and continuing education.