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Role Description

The Compliance Program Director leads the day-to-day operations of the Claims Compliance Program within our Third-Party Administrator (TPA) organization. This role is critical in supporting employer-sponsored health plans by ensuring all operations align with ERISA, federal, and state regulations. A significant focus of this position is ensuring that claims adjudication is accurate and strictly adheres to complex billing standards, health plan requirements, and ERISA mandates. Reporting to the Chief Compliance Officer, you will serve as the organization's Subject Matter Expert (SME) on these standards, providing guidance across all departments.

• Claims Compliance: Provide on-going guidance to the business on claims and compliance-related matters. Act as the primary SME for compliance matters related to claims administration, FWA and billing standards to ensure adjudication processes meet all regulatory and plan-specific requirements.
• Audit Program Leadership: Develop and oversee the internal auditing and monitoring programs to proactively identify risks.
• External Audit Support: Oversee the response and strategy for client-driven external audits and regulatory inquiries, ensuring Collective Health remains a trusted partner for plan sponsors.
• Strategic Planning: Collaborate with the Compliance team to create and implement the Annual Risk Assessment and Compliance Work Plan.
• Policy Development: Support the development and refinement of compliance policies that align with industry benchmarks and the unique functions of a TPA.
• Metrics & Data Integrity: Establish and maintain a robust compliance reporting program to produce reliable metrics and Key Performance Indicators (KPIs) related to auditing outcomes, claims accuracy, and general compliance health.
• Reporting: Prepare detailed reports and updates for the Compliance Officer to share with the Board of Directors and management regarding the health of the compliance program.
• Health Informatics and Product Design: Bridge gap between healthcare claims adjudication workflows, product design and data engineering to improve claims processing.

Qualifications

• Minimum of 15 years in healthcare compliance, specifically within a TPA or Health Plan.
• At least 5 years of experience supervising compliance teams with a focus on coaching and professional development.
• Proven track record of designing and performing complex compliance audits and investigations.
• Deep understanding of U.S. healthcare regulations, claims adjudication, and billing standards.
• Ability to explain the "how" and "why" of compliance programs to diverse stakeholders and build strong cross-departmental relationships.
• Bachelor’s degree required; Masters or Juris Doctorate strongly preferred. CHC certification (or eligibility) is required. RHIA, RHIT, CCS, CPC, CPB, COC, CIC strongly preferred.

Requirements

• This job can be performed in a location where we have an office: San Francisco, CA, Lehi, UT, or Plano, TX, with the expectation of being in office at least two weekdays per week, or hired for remote work in the following states: AZ, CA, CO, CT, FL, GA, IL, MD, MA, MI, MN, NV, NJ, NY, NC, OH, OR, TN, TX, UT, VA, WA, or WI.
• The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity.
• In addition to the salary, you will be eligible for 35,000 stock options and benefits like health insurance, 401k, and paid time off.

Benefits

• Mission-driven culture that values innovation, collaboration, and a commitment to excellence in healthcare.
• Impactful projects that shape the future of our organization.
• Opportunities for professional development through internal mobility opportunities, mentorship programs, and courses tailored to your interests.
• Flexible work arrangements and a supportive work-life balance.