Senior Director, Regulatory Affairs – Delegated Services

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

📋 Description

• Direct the regulatory strategy, governance, and oversight for delegated services encompassing Medicare, Medicaid, and Commercial business lines, ensuring compliance with federal, state, payer, and contractual obligations.

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

• Manage enterprise audit readiness for delegated UM functions, including CMS audits, health plan delegation audits, state regulatory assessments, mock audits, gap analyses, tracer development, documentation evaluations, and remediation planning.

• Drive the creation, implementation, and monitoring of corrective action plans, focusing on root cause analysis, sustainable remediation, and continuous performance oversight.

• Translate and operationalize delegated contractual obligations and state-specific regulatory mandates, encompassing utilization management rules, notice protocols, turnaround times, physician reviewer stipulations, member protections, and delegation oversight standards to ensure operational coherence, compliance governance, and audit defensibility.

• Create and sustain a regulatory framework on a state-by-state basis, including compliance matrices, workflow necessities, regulatory monitoring systems, and control structures to facilitate multi-state delegated operations.

• Formulate regulatory risk escalation pathways, governance frameworks, and remediation strategies for identified compliance vulnerabilities within delegated operations.

• Supervise physician licensing compliance for medical directors, peer reviewers, and other clinical personnel engaged in delegated functions, ensuring appropriate state licensure, tracking of renewals, monitoring of exclusions, and adherence to state-specific reviewer standards.

• Guarantee that delegated services are structured to meet federal, state, contractual, and accreditation benchmarks, including coverage determinations, appeal processes, grievances, timeliness, documentation, and oversight standards.

• Provide regulatory leadership for Medicaid delegated services, including the interpretation of state-specific Medicaid and managed Medicaid requirements, and coordination with plan-specific expectations.

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

• Ensure that delegated workflows facilitate accurate decision-making, timely processing, thorough documentation, and defensible audit results.

• Work together with legal, compliance, and business leaders on delegation-related contract language, oversight frameworks, and risk mitigation approaches.

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

• Keep track of, interpret, and communicate emerging legislative, regulatory, and policy shifts across federal, state, payer, and delegated landscapes, proactively evaluating organizational impact and guiding strategic preparedness.

• Support the development and upkeep of policies and procedures that align with relevant regulatory and accreditation standards, including CMS, NCQA, URAC, and payer-specific delegation criteria.

• Act as a primary point of contact with external health plan partners, auditors, regulators, and accreditation bodies concerning delegated compliance activities.

⛳️ 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 leading and managing audits, including CMS audits, payer delegation audits, and/or state regulatory assessments.

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

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

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

🏝️ Benefits

• Competitive salary and performance-based bonuses.

• Comprehensive health benefits, including medical, dental, and vision coverage.

• Generous paid time off and holiday schedule.

• Opportunities for professional development and continuing education.

• Flexible work arrangements to promote work-life balance.