Sr. Compliance Specialist - Care Management Programs in United States at Jobgether

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Sr. Compliance Specialist - Care Management Programs based in United States.

This role sits at the intersection of healthcare compliance and clinical operations, ensuring care management and utilization management programs operate in full alignment with regulatory, accreditation, and licensing requirements. You will act as a key compliance partner to clinical and operational teams, helping translate complex frameworks such as CMS, NCQA, and URAC standards into practical, day-to-day operational guidance. The position plays a critical role in reducing organizational risk while enabling efficient, high-quality care delivery across multi-state programs. You will collaborate closely with product, operations, and corporate compliance teams to support audits, policy governance, and regulatory readiness. This is a highly cross-functional role requiring both analytical rigor and hands-on operational engagement in a fast-evolving healthcare environment.

In this role, you will serve as the primary compliance expert supporting care management and utilization management operations, ensuring adherence to federal, state, and accreditation requirements while enabling safe and efficient clinical workflows.

• Act as the primary compliance liaison for care and utilization management programs, providing guidance on CMS, NCQA, URAC, and related regulatory frameworks
• Interpret, operationalize, and communicate regulatory requirements into actionable policies, procedures, and operational practices
• Oversee multi-state utilization management licensing compliance, including tracking, renewals, documentation, and regulatory coordination
• Support policy lifecycle management, ensuring documentation remains current, accurate, and aligned with compliance standards
• Monitor regulatory changes and assess operational impact, communicating updates and recommendations to stakeholders
• Partner with clinical, operational, and product teams to embed compliance into workflows, system changes, and program enhancements
• Support audit readiness, accreditation activities, and regulatory reviews, including NCQA and URAC surveys
• Assist with compliance investigations, issue intake, escalation, and remediation efforts across care operations
• Deliver compliance training and ongoing guidance to internal teams to strengthen regulatory awareness and adherence
• Maintain accurate records and documentation to support audits, reporting, and regulatory inquiries

The ideal candidate brings strong healthcare compliance expertise with a solid understanding of managed care operations, clinical programs, and regulatory frameworks, along with the ability to work cross-functionally in complex environments.

• Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or a related field
• 5+ years of experience in healthcare compliance, regulatory affairs, or clinical operations
• Experience supporting utilization management, care management, or disease management programs
• Strong knowledge of CMS regulations and managed care compliance requirements
• Familiarity with NCQA and/or URAC accreditation standards and audit readiness processes
• Understanding of multi-state healthcare regulatory environments and licensing requirements
• Strong analytical and problem-solving skills with attention to regulatory detail and risk mitigation
• Excellent communication skills with the ability to translate regulatory language into operational guidance
• Experience working cross-functionally with clinical, operational, and compliance stakeholders
• Ability to manage multiple priorities in a fast-paced, regulated healthcare environment
• Preferred: clinical background (e.g., RN) or relevant compliance certifications (CHC, CPHQ)

• Competitive salary aligned with experience and healthcare compliance market benchmarks
• Comprehensive medical, dental, and vision insurance with employer contributions
• HSA, FSA, and dependent care spending account options
• 401(k) plan with employer match and immediate vesting
• Fully remote work environment with provided equipment
• Generous paid time off including vacation, sick leave, and holidays
• Paid parental leave for maternity and paternity care
• Employee assistance program with counseling and support services
• Pet insurance and employee discount programs
• Opportunities for professional development and involvement in high-impact healthcare initiatives