Clinical Compliance Program Manager in United States at Jobgether
Explore Related Opportunities
Job Description
This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Clinical Compliance Program Manager in United States.
This role plays a key part in ensuring clinical and operational compliance across post-acute healthcare environments by aligning utilization management practices with federal and state regulatory requirements. You will act as a clinical subject matter expert supporting compliance programs that span CMS, NCQA, and other accreditation standards, helping ensure consistency, accuracy, and regulatory adherence across care settings. The position involves analyzing performance data, conducting audits, and leading root cause investigations to identify improvement opportunities in clinical and operational processes. You will collaborate closely with cross-functional teams to implement policy updates, enhance documentation standards, and support regulatory readiness. The environment is highly analytical and mission-driven, with a strong focus on healthcare quality, compliance excellence, and continuous improvement. This is a remote U.S.-based role with exposure to large-scale healthcare systems and regulatory frameworks.
- Support the organization’s Utilization Management and Compliance Program by ensuring alignment with CMS, NCQA, and other regulatory standards
- Conduct compliance audits, including reviews of expedited, standard, and other case types in accordance with CMS UM requirements
- Perform root cause analysis with operational and clinical teams to identify issues and recommend corrective actions
- Develop, implement, and maintain internal audit protocols aligned with regulatory and accreditation standards
- Generate, validate, and analyze compliance and performance reports across health plan contracts
- Support the preparation for regulatory, accreditation, and contractual audits, including documentation and remediation efforts
- Assist in developing and enforcing clinical and operational policies related to utilization management and compliance requirements
- Monitor regulatory changes and support their integration into internal processes and workflows
- Contribute to the consistency and accuracy of clinical documentation and decision-making practices across teams
- 4–6 years of relevant experience in healthcare compliance, utilization management, or clinical operations
- Strong knowledge of CMS utilization management audits and regulatory requirements (minimum 2–3 years required)
- Experience implementing CMS rule changes and supporting related change management processes
- Bachelor’s degree or equivalent combination of education and clinical experience
- Active, unrestricted clinical license (RN, PT, OT, or SLP preferred)
- Familiarity with NCQA audit processes and healthcare accreditation standards
- Strong analytical skills with the ability to manipulate, interpret, and report complex healthcare data
- Experience managing compliance SLAs and supporting client or organizational audit readiness
- Ability to manage multiple priorities and deadlines in a fast-paced environment
- Strong communication, organizational, and collaboration skills across clinical and operational teams
- Comprehensive medical, dental, and vision insurance with prescription coverage
- Mental health support through employee assistance programs
- Generous paid time off plus 13 paid holidays annually
- 401(k) retirement plan with full vesting from day one
- Tuition and educational assistance up to 2,500 USD per year
- Remote work flexibility within the United States
- Inclusive and collaborative workplace culture focused on innovation and impact
- Drug-free workplace with strong commitment to compliance and integrity