Director of Managed Care Compliance

Join our growing team of dedicated professionals at Gallagher Bassett, who guide those in need to the best possible outcomes for their health and wellbeing. You'll be part of a resilient team that works together to redefine the boundaries of excellence. At our organization, we value collaboration and making a positive impact in the lives of our clients and claimants, offering you the opportunity to join a team where your skills and dedication can truly make a difference. GUIDE. GUARD. GO BEYOND.

We believe that every candidate brings something special to the table, including you! So, even if you feel that you’re close but not an exact match, we encourage you to apply.

We are seeking a detail-oriented and knowledgeable Director of Managed Care Compliance to join our team. This role is responsible for overseeing regulatory compliance within Medical Bill Review, Pharmacy and clinical interventions . The ideal candidate will play a key role in ensuring that our organization adheres to all applicable federal and state regulations, accreditation standards (e.g., NCQA, URAC), and internal policies governing Managed Care functions. A strong understanding of  fee schedules, PPO networks, bill review rules, workers’ compensation statutes as they relate to medical management, insurance operations, and the managed care landscape is essential.

Key Responsibilities:

• Monitor, interpret, and communicate relevant regulatory and legislative changes impacting Managed Care operations, including state-specific regulatory changes and their impact on fee schedules, UCR, application of network rules and discounts, utilization review, pharmacy regulation and statutes
• Serve as subject matter expert in Workers’ Compensation Managed Care compliance space, advising executive leadership and operational teams on regulatory changes, implications to the industry and internal impacts
• Build strong partnerships \ with cross-functional teams to support compliance initiatives, audits, and corrective action plans.
• Develop and maintain compliance programs, policies and procedures as well as overarching compliance position for the organization rooted in industry standards and best practices.
• Provide compliance guidance to claims operations, client services, and other impacted areas to ensure coordinated and consistent approach in alignment with regulation
• Conduct internal reviews and risk assessments to evaluate the effectiveness of compliance controls within Managed Care operations.
• Collaborate with Legal and Regulatory Affairs to ensure consistent interpretation and application of regulatory guidance.
• Monitor, investigate, and document potential compliance issues, recommending appropriate corrective actions as needed.
• Contribute to training and educational programs to promote awareness of regulatory updates and best practices in compliance.
• Maintain thorough documentation and reporting to demonstrate adherence to oversight requirements.

Qualifications:

• Education: Bachelor’s degree required. Advanced degree (e.g., JD, MBA) or professional certifications (e.g., CHC, CHPC, CPC) preferred
• Required: Minimum 5 years relevant experience.

Gallagher offers competitive salaries and benefits, including: medical/dental/vision plans, life and accident insurance, 401(K), employee stock purchase plan, educational expense reimbursement, employee assistance program, flexible work hours (availability varies by office and job function) training programs, matching gift program, and more. 

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