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Job Description: ​

Essential Job Functions:

Markets Compliance for Medicare Advantage and ACO Programs 

• Lead the markets compliance program for Medicare Advantage and ACO programs, including ACO LEAD, ACO REACH, and MSSP regulatory and operational requirements, ensuring compliant program design and execution. 
• Develop and implement policies, procedures, and training specific to markets compliance program operations. 
• Serve as the primary compliance liaison to physician partner groups, medical directors, and market leadership to drive compliance awareness, education, and accountability. 
• Oversee the coordination with health plans and downstream partners on compliance program requirements, audit activity, and corrective action. 
• Monitor and communicate CMS risk adjustment policy developments, enforcement trends, and program-specific requirements across Medicare Advantage and ACO programs. 
• Identify compliance gaps across markets and enterprise operations; communicate risks and remediation recommendations to the CCO, senior leadership and impacted business areas. 
• Collaborate with Legal to confirm ACO compliance obligations are met across applicable CMS direct contracting programs, including ACO REACH, MSSP, and ACO LEAD. 

Risk Adjustment Oversight for Burden of Illness (BOI) and Clinical Pathways 

• Oversee risk adjustment compliance, including regulatory alignment for the Pre-Member Record Review (PMRR) and BOI program, coding audit protocols, and OIG high-risk condition monitoring. 
• Ensure risk adjustment program activities are clinically grounded, well-documented, and audit-ready in alignment with CMS and OIG expectations. 
• Provide regulatory compliance support for clinical pathways, partnering with the Clinical team to ensure program design and execution are compliant, defensible, and aligned with CMS and OIG requirements. 
• Collaborate with Clinical, Legal, and Compliance leadership to identify and mitigate regulatory risk in clinical program design and implementation.  
• Collaborate with Legal to assess the compliance and regulatory standing of clinical pathway vendors, including review of vendor arrangements, program design, and adherence to applicable CMS, OIG, and fraud and abuse requirements. 

Regulatory Change Management 

• Lead regulatory change management, tracking CMS guidance, OIG updates, and federal and state regulatory developments affecting managed care, ACO programs, and value-based care. 
• Assess regulatory and enforcement developments (e.g., FCA settlements, DOJ/OIG actions) and translate findings into actionable compliance guidance for the organization. 
• Maintain current knowledge of OIG compliance requirements for MCOs, FDRs, health plans, and ACO participants. 
• Develop and present compliance metrics, dashboards, and reports for senior leadership and the internal Compliance Committee. 

Required Qualifications:

Education/Licensure:

• Bachelor’s degree in healthcare, business or related field required
• Master’s degree preferred
• CHC preferred; CPC or equivalent risk adjustment coding credential a plus

Minimum Experience:

• 7+ years healthcare compliance experience with significant focus on risk adjustment, regulatory affairs, or managed care compliance. 
• 5+ years compliance auditing and monitoring experience, including audit program management and team oversight. 
• 5+ years supervisory experience managing compliance professionals. 
• Substantial experience with CMS program requirements across Medicare Advantage risk adjustment and ACO programs. 
• Experience at a health plan, health system, provider group or ACO strongly preferred
• Background in managed care operation, risk-based contracting or Medicare Advantage compliance preferred

Skills and Abilities:

• Deep knowledge of OIG compliance requirements for MCOs, FDRs, and ACO participants, including audit expectations and high-risk condition monitoring.
• Expertise with risk adjustment coding, RADV audit processes and supplemental data validation
• Skilled in regulatory change management, including monitoring, analyzing and communicating CMS and OIG guidance and updates
• Strong capability with preparing and delivering board and senior leadership level compliance metrics and reports
• Knowledge of value-based care, Medicare Advantage, fraud and abuse laws, and ACO REACH and MSSP programs.
• Demonstrated leadership, sound independent judgment and the ability to operate effectively in a matrixed organization
• Language Skills: Strong written and verbal communication skills to advise multiple internal clients and external partners in a fast-paced, high-growth environment. 
• Reasoning Ability: Ability to apply legal reasoning and sound judgment to complex, novel regulatory and transactional problems with incomplete information. 
• Computer Skills: Ability to create and maintain documents using Microsoft Office (Word, Excel, Outlook, PowerPoint); familiarity with CLM, matter management, or legal operations platforms preferred. 

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Salary range shown is a guideline. Individual compensation packages can vary based on factors unique to each candidate, such as skill set, experience, and qualifications.