Job Description

SUMMARY

The Compliance and Risk Manager is responsible for overseeing the organization’s enterprise-wide compliance and risk management programs, ensuring adherence to federal, state, and health plan requirements, as well as internal policies and industry standards. This role manages the full compliance framework for both clinical and nonclinical benefit programs—including Non-Emergency Medical Transportation (NEMT), Podiatry, Acupuncture, Chiropractic, Therapy, Optometry, Ophthalmology, and additional specialty care services.

The Compliance and Risk Manager conduct internal audits, leads external and health plan audit responses, manages risk assessments, and partners with cross functional teams to strengthen organizational integrity, operational excellence, and regulatory compliance.

DUTIES & RESPONSIBILITIES

Regulatory Compliance

• Oversee the organization’s compliance program for all clinical and nonclinical benefits, including NEMT, ancillary care, specialty care, and provider delivered benefits.
• Monitor regulatory updates and communicate new or changing compliance requirements across operational departments.
• Maintain, update, and enforce compliance policies, procedures, and training programs.
• Provide guidance to leadership and business units to ensure alignment with federal, state, Medicaid Managed Care, Medicare Advantage, and commercial health plan obligations.

Audit Oversight – Health Plans & External Audits

• Serve as the primary point of contact for all health plan audits, external regulatory audits, accreditation reviews, and delegated oversight audits.
• Lead audit preparation, document collection, corrective action plans, and remediation tracking.
• Coordinate responses to inquiries from state agencies, plan partners, regulators, and accreditation bodies.
• Ensure timely, accurate, and compliant audit submissions across all service lines and business functions.

Risk Management

• Conduct enterprise risk assessments and maintain the organization’s risk register.
• Identify emerging risks in operations, claims processing, vendor management, and program integrity.
• Develop and monitor risk mitigation strategies in collaboration with internal stakeholders.

Investigations & Issue Management

• Conduct investigations involving potential policy violations, regulatory risks, fraud/waste/abuse concerns, or operational failures.
• Coordinate with Legal, HR, and operational teams as appropriate to ensure proper resolution.
• Document all findings, root causes, and remediation outcomes.

Vendor & Third-Party Oversight‑Party Oversight

• Oversee compliance obligations for contractors, subcontractors, transportation providers, and clinical networks.
• Support credentialing verification, exclusion screening compliance, and risk scoring of third-party entities.
• Conduct and oversee delegated vendor audits, corrective action plans, and ongoing monitoring.

Documentation & Reporting

• Prepare compliance reports, board level updates, audit summaries, and risk dashboards.
• Maintain comprehensive documentation related to audits, investigations, policies, training, and mitigation activities.
• Support regulatory submissions as required.

Program Development & Continuous Improvement

• Assist in strategic planning and development of enhancements to the compliance and risk programs.
• Promote a culture of compliance through training, communication, and proactive risk prevention initiatives.
• Identify opportunities to streamline compliance processes and strengthen oversight.
• Oversees and provides direct supervision to the Compliance, Fraud, Waste and Abuse (FWA), and Grievances and Appeals team to ensure regulatory adherence and operational effectiveness.

REQUIREMENTS & QUALIFICATIONS

• Bachelor’s degree in Business, Healthcare Administration, Risk Management, Legal Studies, or related field required.
• Located in Miami, FL, or surrounding areas.
• Certified Professional in Healthcare Compliance (CPHC or CHC) preferred.
• 3–7 years of experience in compliance, risk management, audit, legal, or regulatory affairs.
• Strong knowledge of federal and state regulatory frameworks (e.g., HIPAA, CMS, OIG, OSHA).
• Exceptional analytical, investigative, and problem‑solving abilities.
• High degree of integrity, professionalism, and discretion.
• Ability to effectively present information and respond to questions.

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