Senior Director, Payment Integrity - Regulatory Oversight

📋 Description

• • Provide strategic leadership for the Regulatory and Compliance Oversight function, spearheading initiatives to ensure all Payment Integrity (PI) programs operate in full compliance with federal and state regulations, maintain audit readiness, and exhibit complete traceability across every line of business.
• • Lead and empower teams dedicated to the critical functions of regulatory interpretation, ensuring compliance readiness, coordinating audits, managing evidence, overseeing corrective actions, and staying ahead of regulatory intelligence.
• • Act as the central point of coordination for all enterprise-level regulatory inquiries and market audits, adeptly translating evolving regulatory landscapes into clear, actionable requirements and confirming comprehensive alignment before any deployment.
• • Forge strong partnerships with cross-functional leaders across Claims, Clinical, Finance, Compliance, Provider Relations, Network, Legal, IT, and other PI vertical leaders to enhance governance structures, maintain robust end-to-end traceability, and proactively mitigate regulatory risks through diligent monitoring, transparent communication, and swift issue resolution.
• • Drive the development and execution of sophisticated regulatory alignment strategies for PI edits, audits, recoveries, and vended solutions, ensuring the precise interpretation and consistent application of all federal and state requirements.
• • Establish and rigorously maintain comprehensive governance frameworks, internal controls, documentation standards, and evidence management practices that are foundational for regulatory readiness, end-to-end traceability, and the sustainability of compliance efforts.
• • Oversee the crucial process of regulatory intelligence gathering and insight generation, diligently monitoring new laws, rules, sub-regulatory guidance, and Government Relations (GR) updates to anticipate and address future compliance needs.
• • Direct the end-to-end operations of PI audit intake and response, encompassing meticulous evidence collection, detailed criteria documentation, thorough configuration validation, ongoing sustainment tracking, and the preparation of comprehensive narratives to effectively support market, state, federal, and vendor audits.
• • Provide strategic oversight for Corrective Action Plan (CAP) management, ensuring timely closure, accurate and complete documentation, rigorous sustainment verification, and seamless alignment with enterprise governance processes.
• • Lead the development and delivery of specialized PI-specific regulatory training and knowledge-sharing programs, ensuring all team members possess a deep understanding of requirements, documentation expectations, regulatory impacts, and emerging compliance risks across all programs, markets, and products.
• • Serve as the primary responder to PI-related regulatory inquiries, coordinate audit readiness efforts across Medicaid, Marketplace, and Medicare/Duals hubs, effectively communicate PI regulatory updates to both internal and external stakeholders, and present detailed analyses of regulatory risks, audit outcomes, compliance trends, and proposed mitigation strategies to PI leadership and governance bodies.
• • Proactively interpret and translate complex regulatory updates, guidelines, and Government Relations developments into clear, actionable requirements that directly inform Payment Integrity programs and market operations, ensuring timely alignment and effective mitigation of emerging compliance risks.
• • Foster a high-performing team environment by leading, developing, and mentoring individuals at all levels, cultivating a strong culture of accountability, innovation, continuous improvement, and operational rigor.
• • Perform other duties as assigned to support the overall mission and objectives of the department and the organization.
• • Adhere strictly to all company policies and standards, ensuring a culture of integrity and compliance.