Associate Director, Regulatory Compliance – Medicare & State/ Job Req 822348676 (Sales)

Remote: Full Time must live in one of 6 states where we operate: CA, AZ, NV, TX, WA, OR. Available for Full-Time Work Schedule 8:00am - 5pm Pacific Time, Monday-Friday
PRINCIPLE RESPONSIBILITIES:
Under the direction of the Chief Compliance & Privacy Officer (CCO/CPO), this position is responsible for the regulatory policy, reporting, and programmatic oversight functions within the Compliance Division. This role ensures the organizations ongoing adherence to federal and state regulatory requirements across the Medicare Advantage and Medi-Cal lines of business.
The Associate Director, Regulatory Compliance Medicare & State Program Policy serves as the primary subject matter expert for Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS) and the Center for Medicare and Medicaid Services (CMS) regulatory implementation and leads cross-functional regulatory document readiness, and the execution of required federal and state submissions (e.g., HPMS, DHCS SharePoint, DMHC Portal). This role provides leadership over all other regulatory operations and strategic compliance activities. The Associate Director supervises a team of Medicare and Medi-Cal compliance professionals and ensures enterprise readiness for regulatory audits, tracers, and program reviews.
Principal responsibilities include:
Regulatory Strategy & Policy Oversight
Lead regulatory strategy, interpretation and implementation for CMS, DHCS, and DMHC requirements across Medicare Advantage and Medi-Cal programs.
Translate complex federal and state policy into actionable guidance, workflows, and internal policies.
Oversee review, alignment, and audit readiness of policies and procedures with regulatory standards (HPMS, APLs, DMHC All Plan Letters).
Maintain expertise in applicable CMS Medicare Managed Care Manual chapters (e.g., Ch. 2, 3, 4, 5, 9, 11, 13, 15, 21).
Ensure Medicare and Medi-Cal compliance policies include appropriate privacy, data security, and breach response alignment in collaboration with the Privacy Office.
Ensure annual review, revision, and Board attestation, when necessary, of all Medicare and Medi-Cal policies and procedures under department ownership.
Participate in internal governance committees (e.g., Compliance Committee, Policy Oversight Workgroup) and represent the organization in CMS, DHCS, and DMHC external regulatory meetings, as needed.
Operational Compliance & Regulatory Reporting
Direct day-to-day execution of regulatory submissions, including
CMS HPMS (universes, audits, enrollment);
DHCS SharePoint uploads.
DMHC portal and regulatory filings;
Ensure compliance with marketing review requirements under CMS Chapter 3 and Medi-Cal plan guidance.
Collaborate cross-functionally with operational and clinical leads to support compliance initiatives across plan functions.
Collaborate with Delegation Oversight Team, SIU, Enterprise Risk and Internal Audit functions.
Audit Readiness & Regulatory Engagement
Prepare the plan for CMS Program Audits, ODAG/CDAG universes, Tracer reviews, and readiness assessments.
Represent the plan in CMS, DMHC, and DHCS audits and inquiries.
Support responses to Notice of Deficiencies (NODs), corrective action plans (CAPs), and follow-up reporting.
Collaborate with the Special Investigations Unit (SIU) to ensure alignment of FWA policies and reporting with Medicare and Medi-Cal compliance expectations.
ESSENTIAL FUNCTIONS OF THE JOB:
Update, develop, implement, and maintain organizational policies, procedures, and standards.
Support the development and continuous improvement of the Compliance Program with a focus on Medicare Advantage and Medi-Cal lines of business.
Monitor, track, and audit the compliance program, identify risks, and ensure departmental compliance on an ongoing basis.
Conduct performance reviews, develop training and cross-training plans, and support professional certification goals.
Foster a regulatory culture of accountability, responsiveness, and team collaboration.
Coordinate on investigations and corrective action plans.
PHYSICAL REQUIREMENTS:
Constant and close visual work at desk or computer.
Constant sitting and working at desk.
Constant data entry using keyboard and/or mouse.
Frequent use of telephone headset.
Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
Frequent lifting of folders and various other objects weighing between 0 and 30 lbs.
Occasional driving of automobiles.

Number of Employees Supervised: 7-10
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:
Bachelor's degree required in business, healthcare administration, public health, law, or related field.
Master's degree or JD preferred.
Medicare compliance certification (such as CHC, CCEP, or AHIP Medicare certification) strongly preferred.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

Minimum of 7 years of experience in healthcare compliance, with at least 4 years specifically focused on Medicare Advantage and/or Part D compliance.
Minimum of 3 years of management experience leading compliance teams.
Experience with CMS program audits, validation audits, and/or mock audits.
Experience developing and implementing Medicare compliance programs, policies, and procedures.
Direct experience with a large health plan (500,000+ members) preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

Comprehensive knowledge of Medicare regulations, including 42 CFR Parts 422 and 423, Medicare Managed Care Manual, Prescription Drug Benefit Manual, and related CMS guidance.
Strong understanding of healthcare operations, including claims processing, enrollment, appeals and grievances, pharmacy benefit management, and care management.
Thorough knowledge of compliance program effectiveness and the seven elements of an effective compliance program.
Excellent analytical and problem-solving skills with the ability to identify compliance risks and develop practical solutions.
Strong project management skills with the ability to manage multiple priorities in a fast-paced environment.
Exceptional written and verbal communication skills, including the ability to explain complex regulatory requirements to diverse audiences.
Demonstrated leadership abilities, including team development, coaching, and performance management.
Proficiency with Microsoft Office applications and familiarity with compliance monitoring and reporting tools.
Ability to establish credibility and build collaborative relationships across all levels of the organization.
Strong ethical standards and commitment to integrity in all aspects of the compliance program.
Strong influencing skills and perseverance in investigating.
Demonstrates high integrity and excellent judgment.
Extensive experience with public assistance programs and public agencies. Experience in use of various computer system software as well as Windows, Microsoft Word, Microsoft Excel, Microsoft Outlook and Microsoft PowerPoint.

SALARY RANGE: $167,440.00 - $251,160.00 Annually
The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.