Director, Compliance Programs

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 organizations Subject Matter Expert (SME) on these standards providing guidance across all departments.

What youll do:

• 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.

To be successful in this role youll need:

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

Pay Transparency Statement

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 addition to the salary you will be eligible for 35000 stock options and benefits like health insurance 401k and paid time off. Learn more about our benefits at Francisco CA Pay Range