Senior Director, Healthcare Compliance Risk, Auditing & Monitoring

SR. DIRECTOR, COMPLIANCE RISK, AUDITING & MONITORING The Job The Sr. Director of Compliance Risk, Auditing, & Monitoring is responsible for leading the enterprise-wide identification, assessment, and mitigation of Compliance risks. This role oversees the design and execution of risk-based auditing and monitoring activities, manages the Compliance risk assessment process, and ensures timely and effective development, tracking, and resolution of corrective action plans (CAPs). The Sr. Director provides strategic guidance to ensure regulatory alignment, operational accountability, and the integrity of the organization’s Compliance program. This position partners closely with Compliance leadership, Operations, Legal, and Enterprise Risk to maintain proactive risk visibility and drive a culture of Compliance across all lines of business. You Will

• Build & lead the enterprise Compliance Risk Assessment process, identifying and prioritizing high-risk areas across all health plan lines of business for internal and delegated functions
• Design, build & oversee a risk-based Compliance Auditing and Monitoring program to evaluate enterprise adherence with federal and state regulatory requirements, CMS (Centers for Medicare & Medicaid Services) and DHCS (Department of Health Care Services) protocols, and internal policies and procedures
• Oversee the development and tracking of Corrective Action Plans (CAPs), ensuring integration with Compliance risks and regulatory requirements and demonstrating measurable remediation
• Direct the design and use of enterprise Compliance metrics, dashboards, and monitoring tools to proactively identify risk signals, assess control effectiveness, and support transparency across functional areas, including Medicare Part C/D, claims, risk adjustment, provider networks, quality, and SNP (Special Needs Plan) operations
• Maintain an integrated risk-to-action framework that links risk assessment results, audit findings, monitoring activities, metrics, and CAPs to support traceability, accountability, and governance reporting
• Partner with Compliance, Operations, and Clinical leadership to ensure alignment between Compliance priorities and operational execution, particularly in high-risk areas such as claims accuracy, utilization management, pharmacy benefits, and care management for Medicare Advantage (MA) and SNP populations
• Provide actionable insights to senior leadership and governance committees on Compliance risk posture, audit outcomes, and CAP performance, supporting regulatory readiness and continuous program improvement
• Build, direct and mentor a high-performing team of managers and specialists responsible for executing audits, monitoring reviews, and CAP activities, ensuring alignment to strategic Compliance risk priorities
• Foster a culture of Compliance risk ownership by working cross-functionally to embed audit and monitoring findings into sustainable Operational improvements Though the job is mainly remote, during the initial period of time, when building the function and the team, you will be required to work onsite much of the time. Later on, you will be required to work onsite for a couple of days, 1-2 times/month. We seek talent who are curious about Artificial Intelligence (AI) and its power to transform how we operate and serve our members. Your Qualifications
• Bachelor’s Degree in Business Administration, Public Policy, Public Health, Health Administration or related field required
• Juris Doctor (JD), Master of Health Administration (MHA) or Master of Business Administration (MBA)
• 10+ years Compliance experience in managed care, including Medicare Advantage & Medicaid, or in health insurance company required
• 7+ years management experience preferred
• Health Care Compliance Association certification or Certified in Healthcare Compliance (CHC) or equivalent preferred
• Experience in building and leading a team and function in managed care Compliance risk, auditing & monitoring
• Current working knowledge of Medicare and relevant state health plan regulations, CMS and DHCS audit protocols, fraud, waste, and abuse protocols, and delegated entity oversight standards
• Strong leadership skills with proven ability to manage complex Compliance risks and integration with broader Compliance program
• Excellent written and oral communication skills with ability to present to Board and Executive levels
• Proven ability to interact effectively with staff from all levels of the organization Apply tot his job Apply To this Job

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