VP, Healthcare and Regulatory Compliance
- Lead the development, implementation, and monitoring of compliance policies, procedures, and programs to ensure alignment with CMS, HIPAA, OIG, HHS, OFAC, AML, and FWA requirements.
- Oversee compliance audits, internal investigations, and risk assessments to proactively identify and address compliance concerns.
- Ensure compliance with state and federal laws governing healthcare operations and managed care contracts.
- Promote a culture of compliance and ethical business practices across all levels of the organization.
- Provide guidance and training to employees, executives, and board members on compliance policies and evolving regulations.
- Develop and oversee the corporate compliance program, ensuring a strong internal reporting mechanism for compliance concerns.
- Lead fraud, waste, and abuse (FWA) prevention initiatives, ensuring adherence to federal and state fraud-prevention standards.
- Work with legal counsel and external consultants to investigate and resolve compliance violations.
- Ensure ongoing monitoring of contracts, claims, and financial transactions to identify and mitigate fraud risks.
- Oversee Medicare and Medicaid compliance requirements for contracts with managed care organizations.
- Ensure accurate reporting and documentation in compliance with CMS guidelines.
- Monitor regulatory changes and recommend policy updates to maintain compliance with Medicare Advantage (MA) and Medicaid Managed Care requirements.
- Advise the CEO, board of directors, and senior leadership on compliance risks and strategic regulatory decisions.
- Develop and maintain a comprehensive compliance strategy that aligns with business goals while ensuring regulatory adherence.
- Collaborate with cross-functional teams (legal, finance, HR, and operations) to integrate compliance into all business processes.
- Expertise in regulatory frameworks governing Medicare Advantage, Medicaid Managed Care, and healthcare fraud prevention.
- Deep understanding of CMS regulations and state/federal healthcare laws.
- Strong working knowledge of HIPAA, AML, OFAC, FWA, Stark Law, Anti-Kickback Statute (AKS), and False Claims Act (FCA).
- Expertise in designing and delivering compliance training programs for employees at all levels.
- Exceptional written and verbal communication skills with the ability to engage senior leadership, regulators, external stakeholders and employees at all levels.
- Ability to interpret complex regulations and translate them into practical business policies and procedures.
- Experience in conducting compliance audits, risk assessments, and internal investigations to identify vulnerabilities.
- Ability to develop and implement corrective action plans to mitigate compliance risks.
- Skilled in fraud detection and prevention strategies, particularly in Medicare and Medicaid claims and provider billing.
- Proven ability to design, implement, and update corporate compliance policies that align with regulatory requirements.
- Ability to develop standard operating procedures (SOPs) to support business compliance objectives.
- Experience in managing third-party vendor compliance, including contract review and regulatory risk assessments.
- Proven track record of leading cross-functional teams to integrate compliance within business operations.
- Ability to develop and execute a compliance strategy that supports long-term business growth while ensuring regulatory adherence.
- Ability to foster a culture of ethics, accountability, and compliance awareness across the organization.
- Ability to prepare compliance reports, risk analysis documents, and board presentations.
- Understanding of data privacy and cybersecurity regulations impacting healthcare organizations.
- Ability to leverage data analytics for compliance monitoring and risk assessment.
- Bachelor’s degree (Juris Doctor, MBA, or Master’s in Healthcare Compliance preferred).
- 8+ years of experience in healthcare compliance, with at least 5 years in a senior leadership role.
- Certified in Healthcare Compliance (CHC) or Certified Compliance & Ethics Professional (CCEP) preferred.
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