Director of Compliance and Delegation Oversight

Description

The Director of Compliance and Delegation Oversight leads COPE Health Solutions’ (CHS) enterprise compliance and delegation oversight activities across CHS corporate operations, affiliated and risk-bearing entities, and client engagements. The role ensures that CHS and the organizations it oversees operate in accordance with applicable federal and state requirements, contractual obligations, accreditation standards, program requirements, and internal policies.  This position is accountable for compliance oversight in multiple operating models, including when CHS delegates functions to another party, when CHS serves as the delegated or subcontracted entity, and when CHS provides consulting, advisory, administrative, or operational services. The Director supports CHS IPA, CHS RKK and other risk-bearing arrangements, CHS LEAD and/or Medicare Shared Savings Program (MSSP) ACO activities, TPA and MSO engagements, ARC clients, and other healthcare consulting clients whose operating models may not fit within a traditional health plan, TPA, or MSO structure.

The Director also serves as CHS’s subject-matter expert for Business Associate Agreements (BAAs), leading the review, redlining, negotiation, implementation, and lifecycle management of BAAs and related healthcare privacy and data-sharing provisions in partnership with the Chief Information Security Officer, business leaders, and legal counsel as appropriate.

Position Description: 

• Lead CHS’s enterprise compliance and delegation oversight program, including strategy, risk assessment, policies, procedures, standards, monitoring, reporting, training, and continuous improvement.
• Establish an oversight approach that reflects CHS’s role in each arrangement, including as a delegating entity, delegated entity, downstream contractor, business associate, vendor, risk-bearing provider organization, ACO operator or participant, TPA, MSO, or healthcare consultant.
• Provide compliance leadership across CHS entities, solutions, and client engagements, including but not limited to:
• CHS IPA and other provider network or delegated medical group arrangements.
• CHS RKK and other risk-bearing or value-based care entities and arrangements.
• CHS LEAD and/or MSSP ACO activities and other ACO or accountable care arrangements.
• Client TPA and MSO engagements.
• ARC and other healthcare consulting or advisory clients, including clients for which CHS is not acting as a TPA or MSO.
• When CHS is the delegating entity - maintain a risk-based framework for pre-delegation assessments, onboarding, due diligence, readiness reviews, ongoing monitoring, periodic reevaluation, audits, corrective action, and escalation.
• When CHS is the delegated or contracted entity - lead readiness for health plan, payer, client, regulator, and accreditation oversight; coordinate responses to audits and information requests; track contractual and regulatory deliverables; and oversee remediation of identified deficiencies.
• Evaluate prospective and existing relationships to determine whether activities should be treated as delegation, subcontracting, vendor oversight, business associate services, consulting services, or internal operations, and document the resulting compliance obligations.
• Monitor performance against contractual requirements, regulatory and program obligations, service levels, quality standards, reporting commitments, and internal expectations.
• Lead or coordinate audits and monitoring activities, including audit planning, document requests, file review, interviews, scoring, findings, exit conferences, corrective action plans, validation reviews, and follow-up.
• Review and trend compliance and operational data, including performance metrics, timeliness indicators, audit results, corrective action items, complaints, incidents, and escalation events.
• Manage corrective action plans, remediation timelines, validation reviews, and escalation when performance or compliance issues are not corrected within required timeframes.
• Recommend suspension, limitation, or termination of delegation, subcontracting, vendor, or client arrangements when risk cannot be adequately mitigated.
• Serve as CHS’s BAA subject-matter expert and primary business owner for BAA review and negotiation.
• Review, redline, and negotiate BAAs with clients, health plans, providers, vendors, subcontractors, and other counterparties, using sound legal judgment and approved CHS risk positions.
• Assess and document the parties’ roles and whether a BAA, subcontractor BAA, data use agreement, confidentiality provision, or other data-sharing terms are required, in coordination with privacy, security, and legal resources as appropriate.
• Develop and maintain BAA templates, playbooks, fallback positions, approval thresholds, and escalation protocols; escalate novel, non-standard, or high-risk provisions to the Chief Information Security Officer, executive leadership, and/or legal counsel as appropriate.
• Own the BAA lifecycle, including intake, review, negotiation, approval, execution, tracking, renewal, amendment, termination, and maintenance of a complete and current BAA inventory.
• Advise business leaders and client teams on practical implementation of BAA obligations, including permitted uses and disclosures, subcontractor requirements, incident and breach notification, audit rights, data return or destruction, and termination provisions.
• Support compliance for CHS IPA, CHS RKK, LEAD and/or MSSP ACO, and other value-based care arrangements, including applicable governance, provider or participant oversight, downstream entity monitoring, reporting, audit readiness, and remediation obligations.
• Design compliance approaches for ARC and other consulting clients based on each client’s legal structure, services, risk profile, contracts, and regulatory environment rather than applying a health plan-only framework.
• Prepare and present compliance and delegation oversight reports, dashboards, risk assessments, and issue summaries for senior leadership, governance committees, clients, auditors, regulators, and accreditation bodies.
• Partner with Operations, Quality, Claims, Utilization Management, Care Management, Network Management, Finance, Information Technology, Information Security, Privacy, Human Resources, and client-facing teams to ensure compliance requirements are operationalized and monitored.
• Maintain complete records of agreements, oversight schedules, audit tools, findings, corrective actions, approvals, sanctions, and termination recommendations.
• Ensure timely escalation of significant legal, regulatory, compliance, privacy, security, operational, financial, client, provider, or member/patient-impact risks.
• Support regulatory examinations, accreditation surveys, client audits, internal audits, and external audit responses related to enterprise compliance, delegation, ACO, provider, and client service activities.
• Develop and deliver training for CHS staff, affiliated entities, clients, delegates, subcontractors, and other business partners on compliance, delegation, BAA, documentation, and reporting requirements.
• Review and recommend improvements to compliance and delegation policies, committee charters, contract standards, audit tools, oversight processes, and workflow controls.

Benefits: 

As a firm passionate about health care, we’re deeply committed to the health and wellness of our own team members. We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities, and a paid parental leave program. You can learn more about our benefits offerings here: https://copehealthsolutions.com/careers/ 

About COPE Health Solutions
COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit https://copehealthsolutions.com/about-us/ 

To Apply: 

To apply for this position or for more information about COPE Health Solutions, visit us at https://copehealthsolutions.com/careers/open-positions/