Compliance & Regulatory Audit Manager

Compliance & Regulatory Audit Manager

The Compliance & Regulatory Audit Manager is responsible for overseeing and supporting regulatory compliance, operational audits, delegated oversight, and healthcare compliance initiatives across the IPA/MSO environment. This position is responsible for managing health plan audits, DMHC audits, pre-delegation (Pre-Del) audits, quality management (QM) audits, policy and procedure compliance, corrective action plans, and ongoing regulatory readiness activities. The role ensures organizational compliance with state, federal, health plan, CMS, NCQA, and delegated managed care requirements while supporting operational excellence and risk mitigation initiatives.

Minimum Qualifications Education

Bachelor's degree in Healthcare Administration, Public Health, Business Administration, Compliance, or a related field required.

Required Experience

3-4 years of healthcare compliance, regulatory audit, or managed care operations experience required.

Experience in an MSO, IPA, medical group, managed care organization, health plan, or delegated healthcare environment.

Experience supporting or managing:

• DMHC audits
• Pre-Delegation (Pre-Del) audits
• Quality Management (QM) audits
• Health plan delegated audits
• CMS or NCQA-related compliance activities

Experience developing, implementing, and monitoring corrective action plans (CAPs).

Experience reviewing healthcare operational policies, procedures, and regulatory requirements.

Experience coordinating document collection and audit readiness activities.

Experience working with Medicare Advantage, Medi-Cal, or delegated managed care programs.

Experience communicating with health plans, auditors, providers, operational departments, and leadership teams.

Knowledge of healthcare regulatory standards, compliance requirements, and delegated oversight processes.

Experience maintaining compliance tracking logs, audit reports, and regulatory documentation.

Preferred Experience

Experience supporting Access & Availability audits.

Experience with credentialing oversight and delegated compliance functions.

Experience with utilization management, quality improvement, or population health compliance programs.

Experience supporting annual regulatory filings and health plan reporting requirements.

Experience with policy and procedure development and implementation.

Experience using healthcare compliance tracking systems or reporting tools.

Experience supporting NCQA accreditation or CMS audit preparation.

Experience with Texas TDI and/or AHCCCS

Knowledge, Skills & Abilities

Strong understanding of healthcare compliance, managed care operations, and delegated healthcare environments.

Strong knowledge of DMHC, CMS, NCQA, Medi-Cal, and Medicare Advantage regulatory requirements.

Knowledge of Pre-Delegation (Pre-Del), Quality Management (QM), and health plan audit processes.

Strong understanding of corrective action plans, audit remediation, and compliance monitoring activities.

Excellent organization, project management, and attention to detail.

Strong analytical, problem-solving, and critical-thinking skills.

Ability to manage multiple audits, projects, and deadlines in a fast-paced healthcare environment.

Excellent written and verbal communication skills.

Proficiency in Microsoft Excel, Outlook, Word, PowerPoint, and compliance reporting systems.

Ability to work independently and collaboratively with operational departments and executive leadership.

Ability to maintain confidentiality and comply with HIPAA and healthcare regulatory requirements.

Preferred Certifications

Certified in Healthcare Compliance (CHC) preferred.

Certified Professional in Healthcare Quality (CPHQ) preferred.

NCQA or managed care compliance training preferred.

Project Management Professional (PMP) certification preferred.

Physical & Work Environment

Hybrid or office-based work environment.

Requires extended computer and phone use.

May include occasional meetings with providers, health plans, auditors, and operational departments.

May require participation in on-site audit activities and compliance reviews.