Director, Operations Regulatory and Accuracy Assurance Oversight; Operational Transformation

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

• Advanced proficiency in Microsoft Word, Excel, and Power…