Director, Health Plan Operational Compliance

Job Description Provide leadership, vision, and direction for the defined units within their business area, to include Medicare, Commercial, and FEP Compliance. Lead and set goals for teams responsible for identifying, coordinating, and implementing strategies, frameworks, initiatives/projects and activities that create efficiencies, optimize systems & processes, and promote compliant outcomes. Lead multiple teams united to ensure the integrity within the Health Plan that reflects clear alignment to our enterprise compliance program, as well as regulatory and contractual requirements and policies. Our team creates impact through engagement with business areas to achieve compliant outcomes, including consultative services, project planning, and project leadership, mitigation plan development, compliance audit support and readiness activities, material assurance and agent behavior assurance. What You'll Do Lead the development of the strategy, planning and execution necessary to effectively implement legislation and facilitate implementation of strategies and processes that ensure compliance and achieve operational effectiveness and efficiencies. Direct the maintenance and evaluation of an operational compliance program that is highly effective, meets federal sentencing guidelines and other regulatory requirements, and is deployed to all areas of the Health Plan. The ongoing status of the program is reported to management and the governing body through a committee structure. Develop and deploy communication and training initiatives that support operational compliance goals and obligations. Establish standards and procedures for reporting and documentation, monitoring results against specifications, investigation and mitigation of compliance issues. In partnership with the Enterprise Compliance Office, collaborate with other BCBSNC staff throughout the Health Plan to direct compliance issues to appropriate channels for investigation and resolution. Lead, manage and set goals for teams responsible for identifying, coordinating, and implementing initiatives/projects and activities that create efficiencies, optimize systems & processes, and promote compliant outcomes Provide leadership, vision, and direction for assigned teams: Accountable for all decisions within the group. Determine team priorities to reflect the organization’s core values and deliverables. Develop, coach and motivate others to take actions that support and reflect the core values and desired future state. Develop and manage departmental budgets including forecasting and variance analyses. Lead initiatives to develop, modify, and improve the effectiveness of the department by looking at processes, root cause analysis, system enhancements, re-engineering, etc. Direct staff of subject matter experts and analysts on supporting business initiatives, production problem resolution, system enhancements, and configurations to ensure compliant outcomes Lead and oversee management and delivery of enterprise and departmental projects including business case development, ROI analysis, planning, business analysis, and project management. Lead and oversee optimization of existing systems, processes, and workflows to ensure compliant outcomes. Direct the overall integrity and functionality of departmental business applications and processes o System administration support to include providing guidance on configuration coding, and oversight of system configuration to ensure compliant outcomes. System administration support to include providing guidance on configuration coding, and oversight of system configuration to ensure compliant outcomes. Provide expertise and guidance on product implementation and enhancement to ensure compliant outcomes. Research, analysis, and user assessment of technology and systems to ensure adequate application capabilities to produce compliant outcomes Lead and oversee Operational Compliance strategies, programs, training, and/or policy and procedure development and documentation including interfacing with external audit programs (e.g. DOI, CMS, other third party regulatory bodies). Serve as business owner for key corporate, divisional, and departmental initiatives. What You Have Bachelors degree or Advanced Degree 10 years experience in health insurance, health care operations or legal with at least 4 of those years in a compliance, regulatory and/or Medicare role. Detailed knowledge of state and federal insurance law, especially health insurance and managed care. 5 years of progressive leadership experience. Experience managing remediation of complex compliance issues and legislative implementations. In lieu of degree, 12+ years of experience in related field Bonus Points Strong preference for dual expertise in: Health Care Operational and Compliance leadership Can connect policy → process → compliance outcomes Experience influencing or designing workflows/processes What You’ll Get The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community Work-life balance, flexibility, and the autonomy to do great work Medical, dental, and vision coverage along with numerous health and wellness programs Parental leave and support plus adoption and surrogacy assistance Career development programs and tuition reimbursement for continued education 401k match including an annual company contribution Learn more Where You’ll Work Our Hybrid Flex approach is built on presence with a purpose – giving you flexibility to work remotely with intentional in-person connection – that supports a workplace that’s flexible, connected, and future focused. In a Hybrid-Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually, with a few in-office visits each year for meaningful moments that matter. Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process. Salary Range At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. *Based on annual corporate goal achievement and individual performance. $173,776.00 - $278,041.00 Skills _____________________________________________________________________ JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: View email address on click.appcast.io. About Us It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives. Authorization to Work in the United States We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview for English or Visión General de E-Verify for Español. Request Accommodations Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please notify HR at View email address on click.appcast.io. Blue Cross NC is a Hybrid Flex company. Whether the role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any of our approved states: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming