Job Summary:The Director, Operations Regulatory and Accuracy Assurance Oversight is responsible for representing and leading regulatory, compliance, and accuracy assurance activities on behalf of the Operations division. This senior-level leader serves as the Operations liaison to enterprise Regulatory, Compliance, Audit, and other assurance partners; leads independent evaluation of operational outcomes and processes for accuracy; and advances automation-enabled controls and operational efficiencies.
Essential Functions:- Serve as the Operations liaison and coordinate with enterprise Compliance, Regulatory, Legal, and Audit leaders on behalf of Claims, Configuration, Enrollment, Payment Integrity, Grievance & Appeals, Encounters, and Provider & Member Data.
- Represent Operations internally and externally with regulators and auditors, coordinating responses, requests, audits, investigations, and remediation with the appropriate enterprise partners.
- Partner with operational leaders and Regulatory and Legal teams to interpret and implement laws, regulations, guidance, contracts, and related requirements.
- Lead Operations accuracy assurance, including risk-based and independent auditing of operational outcomes and processes; identify root causes, report findings and trends, and oversee corrective actions through sustainable resolution.
- Establish and advance automated auditing capabilities, including agentic approaches, to expand testing coverage, improve timeliness, and strengthen ongoing monitoring while maintaining appropriate governance and human oversight.
- Lead transformation of Operations teams and workflows to increase automation, accuracy, efficiency, and control effectiveness; define measures of success and monitor realized outcomes.
- Monitor regulatory and legislative changes and coordinate timely communication and implementation across impacted Operations areas.
- Draft clear, timely operational responses for state agencies, departments of insurance, and other regulators in coordination with internal stakeholders.
- Maintain integrated tracking and reporting for regulatory, compliance, audit, and accuracy assurance matters, including risks, action plans, and remediation status.
- Keep direct-line leadership and the Corporate Compliance Officer informed of material regulatory initiatives, compliance concerns, accuracy risks, operational issues, and associated corrective actions; provide Operations status reporting to the Corporate Compliance Officer and applicable committees.
- Build strong relationships with key leaders and business partners to identify, prioritize, and mitigate operational and compliance risks.
- Perform any other job related duties as requested.
Education and Experience:- Bachelor's degree in business or related field required
- Master's degree preferred
- Equivalent years of relevant work experience may be accepted in lieu of required education
- Five (5) years of healthcare operations experience including three (3) years in Government Program products required
- Five (5) years of leadership experience required
- Experience leading operational accuracy assurance, quality auditing, control testing, or equivalent assurance activities is required
- Demonstrated experience transforming operational teams and processes through automation, workflow redesign, and measurable efficiency improvement is required
- Demonstrated experience applying automation and artificial intelligence to operational auditing or monitoring, including agentic use cases, governance, validation, human oversight, and sustained production performance is preferred
- Compliance oversight leadership experience within healthcare operations strongly preferred
Competencies, Knowledge and Skills:- Advanced proficiency in Microsoft Word, Excel, and PowerPoint
- Strong data analysis, trending, root-cause analysis, and performance measurement skills
- Deep knowledge of healthcare operations concepts, practices, procedures, and accuracy-control frameworks
- Demonstrated understanding of compliance and regulatory requirements for managed care and government programs, including CMS, HHS, departments of insurance, and Medicaid agencies
- Knowledge of automated auditing, continuous monitoring, artificial intelligence, and agentic solutions, including appropriate governance, testing, validation, and escalation controls
- Ability to translate assurance findings and operational data into prioritized actions, sustainable process improvements, and executive-level reporting
- Demonstrated transformation leadership, including operating-model design, workflow automation, change management, and benefits realization
- Strong strategic leadership, stakeholder management, negotiation, and decision-making skills
- Excellent written and verbal communication skills
- Ability to work independently and collaboratively, manage competing priorities and project timelines, and maintain strong attention to detail
- Customer-focused critical thinking, listening, and problem-solving skills
Licensure and Certification:- Certified in Healthcare Compliance (CHC) preferred
Working Conditions:- General office environment; may be required to sit or stand for extended periods of time
- Ability to travel as required by the needs of the business.
Compensation Range:
$113,000.00 - $197,700.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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