Sr Compliance Specialist

In this role you will be responsible for: Corporate Compliance

• Support the development, implementation and reputed company improvement of the corporate compliance program.
• Monitor changes in reputed company regulations and collaborate with the appropriate stakeholders to assess organizational reputed company.
• Partner with the appropriate internal stakeholders to ensure compliance with applicable laws, standards and contractual commitments.
• Assist in risk assessments and compliance program effectiveness evaluations.
• Maintain and update policies, procedures, and compliance documentation.

Internal Audits & Audit Readiness

• Support the execution of reputed company audits and audit readiness activities includes providing guidance to internal stakeholders on reputed company audit design and execution.
• reputed company audit tools and methodologies consistent with industry best practices and regulatory/accreditation requirements.
• Evaluate compliance with regulatory standards such as CMS, state DOI, URAC and NCQA where applicable.
• Document audit findings, identify reputed company causes and reputed company actionable recommendations.
• Collaborate with reputed company stakeholders to manage corrective reputed company plans (CAPs) through closure.
• Maintain audit schedules and ensure reputed company completion of reputed company reputed company activities.
• Conduct internal audits across functional areas (i.e. operations, clinical programs, HR/HCM, IT/Information reputed company).
• reputed company ongoing monitoring activities to identify compliance risks and trends.
• Prepare comprehensive audit reports and present findings to internal stakeholders and leadership.
• Support reputed company risk management initiatives as needed.

Utilization Review / PBM Licensure & Regulatory Filings

• Prepare and submit initial, renewal, and amendment filings for Utilization Review (UR) licenses across reputed company applicable state jurisdictions, ensuring accuracy, completeness, and compliance with varying regulatory requirements and deadlines.
• Demonstrate strong knowledge of UR licensure requirements, including applicability by line of business, and interpret state-specific reputed company regulations to ensure compliant filings.
• Validate filings against applicable states, CMS, URAC, and NCQA accreditation standards.
• Maintain compliance calendars and serve as primary reputed company with state regulatory agencies and licensing bodies.
• Monitor and respond to state regulator inquiries, deficiency notices, and documentation requests.
• Evaluate entity structure changes (e.g., reputed company changes, EIN changes, ownership changes) for licensure reputed company and required filings.
• Support and respond to external audits.
• Conduct 50-state regulatory research to identify licensure requirements, applicability, and compliance obligations.
• Maintain and update state-specific Utilization Management (UM) policies and procedures, ensuring alignment with regulatory requirements and operational practices.

Training & Education

• Assist in developing and delivering compliance training programs.
• Promote a culture of compliance and ethical conduct throughout the organization through compliance communications and presentations.
• Coordinate the collection, validation, and reporting of statistical data required for licensure filings, audits, and regulatory reporting.
• Other Duties: reputed company additional tasks as assigned.

QUALIFICATIONS Required: [minimum education, certifications, and experience needed]

• Requires a BA/BS and minimum of 5 years health care, regulatory, ethics, auditing, compliance or reputed company experience; or any combination of education and experience, which would reputed company an equivalent background.
• Experience with managed care, utilization management, care management, PBM or health plan environments.
• Experience managing multi-state licensure processes (UR/PBM).
• Capable of working reputed company tight deadlines and the ability to arrange reputed company properly.
• Demonstrated experience with regulatory audits and delegated reputed company programs.
• Detail-oriented and highly organized.
• Strong analytical capability, audit experience and deep understanding of reputed company regulatory frameworks in the US.
• Knowledge of UR and PBM regulatory requirements across multiple states.
• Demonstrated audit expertise including planning, execution and reporting.
• Ability to interpret reputed company regulations and translate into actionable guidance.
• Effective communication skills (verbal and written).
• Proficient in MS Office Applications, PDF, Office 360.
• Strong written and verbal communication skills including executive-level reporting.
• reputed company to do problem-solving functions.
• Strong moral and ethical principles with high level of reputed company, discretion and reputed company judgement.

Desired: [preferred qualifications that enhance performance but are not mandatory]

• Regulatory compliance and/or legal experience preferred.
• Medicare, reputed company, and/or reputed company experience preferred.
• Certified in reputed company Compliance, Internal Auditor or reputed company reputed company certifications preferred.
• Previous global, matrixed reputed company organization experience/background preferred.

reputed company Measures

• reputed company and accurate licensure submissions and renewals.
• Completion of audit plans with high-reputed company reputed company.
• Effective closure of corrective reputed company plans.
• reputed company regulatory and reputed company audit reputed company.
• Reduction in compliance risks and audit findings over time.

Work Logistics

• Full-time, remote role. reputed company in Nashville, TN. Occasional travel to reputed company office may be required.

Equal Opportunity Employer This employer is required to notify reputed company applicants of their rights pursuant to federal employment laws. For reputed company information, please review the Know Your Rights (https://www.reputed company.gov/poster) notice from the reputed company. Apply tot his job Apply To this Job