Senior Compliance Advisor, State Health Plan(SHP)

Blue Cross and Blue Shield of North Carolina; North Carolina; Hybrid; USD 81,000 - 130,000; Full time

Job summary

Blue Cross NC is seeking a senior compliance professional to independently resolve enterprise-wide questions affecting SHP benefits, operations, clinical programs, and vendor relationships.

You will act as a compliance SME for Case Management and Utilization Management, interpret NCQA and state requirements, and translate them into policies, controls, and implementation plans. Collaboration across departments will be key.

Qualifications

• Bachelor's degree or advanced degree with 5+ years in related field.
• In lieu of degree, 7+ years of experience in related field.
• Substantial healthcare compliance experience and regulatory knowledge.
• Familiarity with Case Management and Utilization Management roles and requirements.

Responsibilities

• Apply deep healthcare compliance expertise to resolve complex enterprise questions.
• Serve as compliance SME for clinical programs, benefits, and vendor relations.
• Research and interpret NCQA, state, ERISA, MHPAEA and related requirements.
• Advise leaders on compliance implications and practical solutions.
• Partner with multiple stakeholders to resolve cross-functional compliance matters.
• Conduct risk assessments, audits, and reviews; monitor metrics and actions.
• Assist with internal quality improvement plans and root-cause analysis.
• Evaluate parity and CM/UM requirements across physical and behavioral health.

Skills

Healthcare compliance

Regulatory affairs

Policy development

Risk assessment

Education

Bachelor's degree or advanced degree

Job description

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

About Us

It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care - in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

Authorization to Work in the United States

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Request Accommodations

Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application, hiring process, or have technical issues that prevent you from completing your application please notify HR at [e-mail].

Location & Work Arrangement

Blue Cross NC is a Hybrid Flex company. Whether the role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any of our approved states: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.