Job Description

The Senior Compliance Advisor, State Health Plan (SHP), leads the day-to-day activities required to maintain an effective compliance program for SHP operations and health plan administration. This role coordinates highly complex, cross-functional matters involving physical and behavioral health benefits, Case Management, Utilization Management, delegated entities, vendors, and clinical operations. The advisor identifies compliance risks; interprets and operationalizes applicable requirements; develops or facilitates corrective action plans; and conducts audits and compliance reviews to monitor ongoing adherence to NCQA standards, North Carolina Department of Insurance requirements, ERISA, the Mental Health Parity and Addiction Equity Act (MHPAEA), contractual obligations, and all other applicable federal and state laws and regulations.

What You'll Do

• Apply deep healthcare compliance and regulatory expertise to independently resolve complex, enterprise-wide questions affecting SHP benefits, operations, clinical programs, and vendor relationships.
• Serve as a compliance subject matter expert for physical and behavioral health Case Management and Utilization Management, including medical necessity review, care coordination, appeals, grievances, member protections, and delegated functions.
• Research and interpret new or changing requirements, including NCQA standards, North Carolina Department of Insurance requirements, ERISA, MHPAEA, plan documents, contracts, and other federal and state laws, and translate them into clear operational guidance, policies, controls, and implementation plans.
• Advise business leaders on compliance implications and recommend practical solutions that balance regulatory obligations, clinical integrity, member experience, and operational needs.
• Partner with SHP leadership, Legal, Clinical, Case Management, Utilization Management, Behavioral Health, Appeals and Grievances, Network, Benefits, Operations, Vendor Management, and other stakeholders to resolve cross-functional compliance matters.
• Conduct risk assessments, audits, and compliance reviews of business processes, clinical programs, systems, vendors, and delegated entities; monitor compliance metrics and emerging risks; and confirm corrective and preventive actions are implemented, sustained, and validated.
• Assist with initiating internal quality improvement plans (QIPs) based on audit findings, partnering with the Education team on root cause analysis, targeted training and remediation, and progress tracking.
• Evaluate MHPAEA and parity compliance across physical and behavioral health programs, including financial requirements, quantitative and nonquantitative treatment limitations (such as UM criteria, prior authorization, network standards, and reimbursement), and related access, timeliness, notice, and member communication requirements.
• Support SHP readiness for NCQA surveys and other regulatory or accreditation reviews, including evidence collection, gap assessment, interview preparation, and remediation tracking.
• Lead analysis of the enterprise and SHP regulatory environment to recommend compliance programming, monitoring, governance, and risk mitigation initiatives.
• Develop training, tools, and communications for employees, leaders, vendors, and delegated entities to promote consistent execution of compliance requirements.
• Review policies, procedures, workflows, clinical documents, contracts, benefit booklets, plan documents, and marketing and member-facing materials (SHP and commercial) for compliance, providing clear, actionable feedback and supporting development as needed.
• Provide coaching and technical guidance to less experienced team members and may coordinate work across compliance initiatives.

What You Bring

• Bachelor's degree or advanced degree (where required)
• 5+ years of experience in related field.
• In lieu of degree, 7+ years of experience in related field.

Bonus Points(Preferred Qualifications)

• Substantial experience in healthcare compliance, health plan operations, clinical operations, regulatory affairs, accreditation, or a related field.
• Demonstrated understanding of both Case Management and Utilization Management roles, responsibilities, workflows, documentation, and regulatory requirements across physical and behavioral health.
• Working knowledge of NCQA accreditation standards, North Carolina Department of Insurance requirements, ERISA, MHPAEA and related behavioral health parity requirements, including comparative analyses of nonquantitative treatment limitations, and other federal and state requirements applicable to SHP.
• Experience assessing delegated entities, vendors, or clinical programs and translating regulatory requirements into sustainable operational controls.
• Ability to evaluate complex issues through clinical, regulatory, operational, and member-impact lenses and communicate recommendations to executive and operational audiences.
• Strong judgment, analytical skills, influence, and cross-functional leadership, with the ability to manage multiple high-risk priorities in a complex healthcare environment.
  
  

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets,  licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. 

*Based on annual corporate goal achievement and individual performance.
 

$81,068.00 - $129,708.00

Skills

Compliance Activities, Compliance Analysis, Compliance Program Development, Compliance Programs, Compliance Reviews, Compliance Training, Legal Regulatory Compliance, Medicare Compliance, Policy Compliance, Regulatory Compliance

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