VP, Healthcare and Regulatory Compliance

Overview

This executive leader ensures that all policies, procedures, and business activities align with regulatory requirements, including AML, HIPAA, OFAC, FWA, and CMS regulations; the role requires deep expertise in healthcare compliance, risk management, and regulatory affairs to mitigate compliance risks and foster a strong culture of ethics and integrity throughout the organization. The VP of Healthcare and Compliance will work closely with executive leadership, legal teams, and operational departments to maintain a robust compliance program that supports business objectives while ensuring regulatory adherence.

• Lead the development, implementation, and monitoring of compliance policies, procedures, and programs to ensure alignment with CMS, HIPAA, OIG, HHS, OFAC, AML, and FWA requirements.
• Oversee compliance audits, internal investigations, and risk assessments to proactively identify and address compliance concerns.
• Ensure compliance with state and federal laws governing healthcare operations and managed care contracts.
• Promote a culture of compliance and ethical business practices across all levels of the organization.
• Provide guidance and training to employees, executives, and board members on compliance policies and evolving regulations.
• Develop and oversee the corporate compliance program, ensuring a strong internal reporting mechanism for compliance concerns.
• Lead fraud, waste, and abuse (FWA) prevention initiatives, ensuring adherence to federal and state fraud-prevention standards.
• Work with legal counsel and external consultants to investigate and resolve compliance violations.
• Ensure ongoing monitoring of contracts, claims, and financial transactions to identify and mitigate fraud risks.
• Oversee Medicare and Medicaid compliance requirements for contracts with managed care organizations.
• Ensure accurate reporting and documentation in compliance with CMS guidelines.
• Monitor regulatory changes and recommend policy updates to maintain compliance with Medicare Advantage (MA) and Medicaid Managed Care requirements.
• Advise the CEO, board of directors, and senior leadership on compliance risks and strategic regulatory decisions.
• Develop and maintain a comprehensive compliance strategy that aligns with business goals while ensuring regulatory adherence.
• Collaborate with cross-functional teams (legal, finance, HR, and operations) to integrate compliance into all business processes.

• Expertise in regulatory frameworks governing Medicare Advantage, Medicaid Managed Care, and healthcare fraud prevention.
• Deep understanding of CMS regulations and state/federal healthcare laws.
• Strong working knowledge of HIPAA, AML, OFAC, FWA, Stark Law, Anti-Kickback Statute (AKS), and False Claims Act (FCA).
• Expertise in designing and delivering compliance training programs for employees at all levels.
• Exceptional written and verbal communication skills with the ability to engage senior leadership, regulators, external stakeholders and employees at all levels.
• Ability to interpret complex regulations and translate them into practical business policies and procedures.
• Experience in conducting compliance audits, risk assessments, and internal investigations to identify vulnerabilities.
• Ability to develop and implement corrective action plans to mitigate compliance risks.
• Skilled in fraud detection and prevention strategies, particularly in Medicare and Medicaid claims and provider billing.
• Proven ability to design, implement, and update corporate compliance policies that align with regulatory requirements.
• Ability to develop standard operating procedures (SOPs) to support business compliance objectives.
• Experience in managing third-party vendor compliance, including contract review and regulatory risk assessments.
• Proven track record of leading cross-functional teams to integrate compliance within business operations.
• Ability to develop and execute a compliance strategy that supports long-term business growth while ensuring regulatory adherence.
• Ability to foster a culture of ethics, accountability, and compliance awareness across the organization.
• Ability to prepare compliance reports, risk analysis documents, and board presentations.
• Understanding of data privacy and cybersecurity regulations impacting healthcare organizations.
• Ability to leverage data analytics for compliance monitoring and risk assessment.

• Bachelor’s degree (Juris Doctor, MBA, or Master’s in Healthcare Compliance preferred).
• 8+ years of experience in healthcare compliance, with at least 5 years in a senior leadership role.
• Certified in Healthcare Compliance (CHC) or Certified Compliance & Ethics Professional (CCEP) preferred.

Nations Benefits is an Equal Opportunity Employer.