Position Summary

The Compliance Manager is responsible for overseeing All Payer Claims Database (APCD) reporting and compliance activities. This role ensures the company meets state regulatory requirements, manages communications with regulators and vendors, coordinates reporting deadlines, and translates regulations into business requirements. The position also supports process improvements, issue resolution, team training, and cross-functional collaboration.

Key Responsibilities

• Manage APCD compliance programs and reporting requirements across multiple states.
• Lead projects from start to finish, including timelines, regulator communications, and extension requests.
• Interpret state regulations and convert them into business and system requirements.
• Oversee timely submission of reports, files, and responses to regulators and vendors.
• Investigate compliance, reporting, and system issues; identify root causes and support corrective actions.
• Write detailed business requirements to address compliance and data issues.
• Use reporting tools, databases, and data analysis to monitor compliance and improve processes.
• Identify opportunities to automate and streamline workflows.
• Train, mentor, and coach team members and business partners.
• Develop and maintain training materials, policies, procedures, and process documentation.
• Build relationships across departments to improve collaboration and results.
• Communicate effectively with regulators, vendors, clients, account managers, IT teams, and leadership.
• Escalate risks, issues, and compliance concerns when appropriate.
• Create management reports and provide recommendations for issue resolution.

Required Qualifications

• 5+ years of compliance or legal experience in healthcare, insurance, or financial services.
• 5+ years of experience with healthcare products, including:
  • HMO
  • PPO
  • Medicare Advantage
  • Medicare Part D
• 2+ years of pharmacy-related experience, including:
  • Specialty drugs
  • Medicare Part D
  • PBM (Pharmacy Benefit Manager) operations
• Understanding of healthcare claims processing and industry coding structures.
• Ability to travel up to 10%.

Preferred Qualifications

• 4–6 years of data analysis and interpretation experience.
• 5–8 years of experience using tools such as SAS, SQL, ACL, Excel, databases, and Microsoft Office.
• Strong experience working with and analyzing large datasets.
• 8+ years of healthcare industry experience, including interpreting state and federal regulations.
• 3–5 years of project management and process improvement experience.
• 3+ years of direct compliance experience involving regulatory agencies.

Key Skills

• Strong project management and organizational skills.
• Ability to manage multiple priorities and deadlines.
• Excellent written and verbal communication skills.
• Ability to influence business processes, policies, and system improvements.
• Strong analytical and problem-solving abilities.
• Experience identifying trends, conducting root-cause analysis, and improving data quality.
• Ability to build relationships and collaborate across teams.

Education

• Bachelor’s degree or equivalent work experience.