Director of Value Based Care Regulatory Compliance

Agilon Health, Inc.; Kentucky; Hybrid; USD 115.000 - 191.000; Vollzeit

Zusammenfassung

AHI agilon health, inc. is seeking a Director of Value Based Care Regulatory Compliance to lead markets compliance for Medicare Advantage and ACO programs, including ACO REACH and MSSP, with a focus on risk adjustment and day-to-day regulatory operations.

You will oversee PMRR/BOI programs, regulatory change management, and collaborate with Clinical, Legal, and Compliance leadership to mitigate risk and ensure audit readiness.

Qualifikationen

• Bachelor’s degree in healthcare, business or related field required.
• Master’s degree preferred; CHC preferred; CPC or equivalent risk adjustment coding credential a plus.
• 7+ years healthcare compliance experience with focus on risk adjustment, regulatory affairs, or managed care compliance.
• 5+ years compliance auditing and monitoring experience, including audit program management and team oversight.
• 5+ years supervisory experience managing compliance professionals.
• Substantial experience with CMS program requirements across Medicare Advantage risk adjustment and ACO programs.

Aufgaben

• Lead markets compliance for Medicare Advantage and ACO programs, including ACO LEAD, ACO REACH, and MSSP regulatory requirements.
• Oversee risk adjustment compliance, including PMRR and BOI program, coding audit protocols, and OIG monitoring.
• Lead regulatory change management; track CMS guidance, OIG updates, and federal/state developments; provide metrics for leadership.

Kenntnisse

OIG compliance

Risk adjustment coding

Regulatory change mgmt

Leadership metrics

Value-based care

ACO programs

Ausbildung

Bachelor's degree

Master's degree preferred

CHC preferred

CPC credential

Jobbeschreibung

Company: AHI agilon health, inc. Job Posting Location: Remote - USA Job Title: Director of Value Based Care Regulatory Compliance

Essential Job Functions

• Markets Compliance for Medicare Advantage and ACO Programs Lead the markets compliance program for Medicare Advantage and ACO programs, including ACO LEAD, ACO REACH, and MSSP regulatory and operational requirements, ensuring compliant program design and execution. Develop and implement policies, procedures, and training specific to markets compliance program operations. Serve as the primary compliance liaison to physician partner groups, medical directors, and market leadership to drive compliance awareness, education, and accountability. Oversee the coordination with health plans and downstream partners on compliance program requirements, audit activity, and corrective action. Monitor and communicate CMS risk adjustment policy developments, enforcement trends, and program-specific requirements across Medicare Advantage and ACO programs. Identify compliance gaps across markets and enterprise operations; communicate risks and remediation recommendations to the CCO, senior leadership and impacted business areas. Collaborate with Legal to confirm ACO compliance obligations are met across applicable CMS direct contracting programs, including ACO REACH, MSSP, and ACO LEAD.
• Risk Adjustment Oversight for Burden of Illness (BOI) and Clinical Pathways Oversee risk adjustment compliance, including regulatory alignment for the Pre-Member Record Review (PMRR) and BOI program, coding audit protocols, and OIG high-risk condition monitoring. Ensure risk adjustment program activities are clinically grounded, well-documented, and audit-ready in alignment with CMS and OIG expectations. Provide regulatory compliance support for clinical pathways, partnering with the Clinical team to ensure program design and execution are compliant, defensible, and aligned with CMS and OIG requirements. Collaborate with Clinical, Legal, and Compliance leadership to identify and mitigate regulatory risk in clinical program design and implementation. Collaborate with Legal to assess the compliance and regulatory standing of clinical pathway vendors, including review of vendor arrangements, program design, and adherence to applicable CMS, OIG, and fraud and abuse requirements.
• Regulatory Change Management Lead regulatory change management, tracking CMS guidance, OIG updates, and federal and state regulatory developments affecting managed care, ACO programs, and value-based care. Assess regulatory and enforcement developments (e.g., FCA settlements, DOJ/OIG actions) and translate findings into actionable compliance guidance for the organization. Maintain current knowledge of OIG compliance requirements for MCOs, FDRs, health plans, and ACO participants. Develop and present compliance metrics, dashboards, and reports for senior leadership and the internal Compliance Committee.

Required Qualifications

• Education/Licensure Bachelor’s degree in healthcare, business or related field required. Master’s degree preferred. CHC preferred; CPC or equivalent risk adjustment coding credential a plus.
• Minimum Experience 7+ years healthcare compliance experience with significant focus on risk adjustment, regulatory affairs, or managed care compliance. 5+ years compliance auditing and monitoring experience, including audit program management and team oversight. 5+ years supervisory experience managing compliance professionals. Substantial experience with CMS program requirements across Medicare Advantage risk adjustment and ACO programs. Experience at a health plan, health system, provider group or ACO strongly preferred. Background in managed care operation, risk-based contracting or Medicare Advantage compliance preferred.

Skills and Abilities

• Deep knowledge of OIG compliance requirements for MCOs, FDRs, and ACO participants, including audit expectations and high-risk condition monitoring.
• Expertise with risk adjustment coding, RADV audit processes and supplemental data validation.
• Skilled in regulatory change management, including monitoring, analyzing and communicating CMS and OIG guidance and updates.
• Strong capability with preparing and delivering board and senior leadership level compliance metrics and reports.
• Knowledge of value-based care, Medicare Advantage, fraud and abuse laws, and ACO REACH and MSSP programs.
• Demonstrated leadership, sound independent judgment and the ability to operate effectively in a matrixed organization.

Language Skills

• Strong written and verbal communication skills to advise multiple internal clients and external partners in a fast-paced, high-growth environment.

Reasoning Ability

Ability to apply legal reasoning and sound judgment to complex, novel regulatory and transactional problems with incomplete information.

Computer Skills

• Ability to create and maintain documents using Microsoft Office (Word, Excel, Outlook, PowerPoint); familiarity with CLM, matter management, or legal operations platforms preferred.

Location and Compensation

Location: Remote - OH

Pay Range: $153,000.00 - $191,300.00 Salary range shown is a guideline. Individual compensation packages can vary based on factors unique to each candidate, such as skill set, experience, and qualifications.

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Passion & Purpose

The passion to change the way healthcare is delivered permeates everyone and everything at agilon health. Working together we can use our expertise to make a difference in the lives of patients and physicians alike. We can bring the joy back to practicing medicine for physicians and improve the care experience for patients across the country.

Privacy & Trust

We value your privacy and trust as much and are committed to protecting your personal information and respecting your choices. We use technology and best practices to ensure that your data is secure and compliant with applicable laws and regulations. We also provide you with clear and transparent information about how we collect, use, and share your data, and how you can access, update, or delete it. You can read our full privacy policy click here Beware of recruitment scams - our company will never ask for payment or personal financial information during the hiring process; if you believe you've been contacted fraudulently, please reach out to our official recruiting team immediately at [e-mail].

Equal Opportunity Employer

agilon health is committed to excellence through diversity. We are an equal opportunity employer and we will not discriminate against employees or qualified applicants for employment regardless of race; color; religion; genetic information; national origin; sex; pregnancy, childbirth, or related medical conditions; age; disability; citizenship status; uniform service member status; or any other protected class under federal, state, or local law. We strive to develop leaders and build future talent pools to help us meet the needs of our customers. If you need assistance or an accommodation due to a disability, you may email us at [e-mail].