Regulatory Compliance Principal

Overview

Position Overview: 

The Regulatory Compliance Principal will be the subject matter expert in healthcare regulatory compliance with a passion for leveraging innovative technology to address critical needs in healthcare. This individual will play a pivotal role in ensuring that our suite payer-focused software products support our customers in achieving and maintaining compliance with federal, state, and accreditation body requirements. The Director, Regulatory Compliance will serve as a strategic advisor to internal and external stakeholders, driving regulatory adherence and aligning our products with the ever-evolving healthcare landscape.

The Product:

With HealthRules Payer, our integrated solutions suite includes the industry's leading, digital, next-generation claims administration processing system, business intelligence, integration capabilities, a unique to industry configuration and promotion application, and home and host processing support available on both public and private clouds. The fact is, a Core Administrative Processing System (CAPS) needs to do much, more more than just core administrative processing. That’s why HealthRules Payer has been ranked number one its class among CAP Solutions. Besides delivering 90%-97% first-pass auto-adjudication rates and 99%+ accuracy, it enables our customers to react swiftly to the latest regulatory shifts and competitive pressures. It opens the door to new value-based reimbursement models, benefits plans and provider contracts. The complete suite of solutions from HealthEdge delivers a digital foundation for payers specifically designed to fuel a digital transformation, reduce costs, and improve both clinical outcomes and the member experience.

 

Your Impact:

Regulatory Expertise:

• Proactively monitor, interpret, and analyze NCQA, URAC, CMS, and state regulatory requirements and updates, providing actionable insights for our products and customers.
• Partner with Legal and Compliance teams to identify and document clinical and payer-specific regulations relevant to our product portfolio.
• Serve as the subject matter expert and advisor on healthcare regulations, ensuring stakeholders understand the implications for our products and our customers’ operations.
• Research trends and developments in governmental regulations to inform the product roadmap and strategic planning.

Product Alignment:

• Collaborate with Product and Marketing teams to position our software solutions as tools to enhance compliance and drive customer success.
• Identify areas of non-compliance within applications, services, and processes, developing action plans to mitigate risks.
• Develop and maintain a compliance scorecard to monitor adherence across the product portfolio, driving continuous improvement.
• Support product development by defining business cases and requirements for new features or enhancements that align with regulatory standards.

Customer and Stakeholder Engagement:

• Communicate regulatory changes clearly and effectively to internal and external audiences through briefs, user groups, blogs, and 1:1 customer sessions.
• Partner with customers to address compliance-related inquiries and provide guidance on best practices for implementing regulatory requirements.
• Deliver internal training sessions on regulatory updates and compliance requirements to enhance organizational knowledge and alignment.

Audit Readiness and Reporting:

• Lead regulatory survey readiness planning for accreditations and certifications.
• Ensure workflows, policies, and procedures are in place to meet relevant regulatory and accreditation requirements.
• Assist Customer Support in triaging and resolving compliance issues reported by customers.

What You Bring:

• Bachelor’s degree in a healthcare-related field required; advanced degree (e.g., law, clinical) preferred.
• 7+ years of experience in healthcare compliance, with a focus on Medicare, Medicaid, NCQA, CMS, URAC, and state regulatory requirements.
• Extensive experience in the payer space, with knowledge of health plan operations and their digital transformation needs.
• Demonstrated experience working with regulatory requirements in a software product development environment.
• Advanced understanding of healthcare regulations, including HEDIS, CMS reporting, and audit requirements.
• Ability to interpret complex regulations and translate them into actionable business solutions.
• Strong interpersonal, communication, organizational, and coordination skills.
• Analytical and storytelling capabilities to educate and align internal and external audiences on compliance matters.