Pbm Compliance Jobs (NOW HIRING)

In this role you will be responsible for:

Corporate Compliance

• Support the development, implementation and continuous improvement of the corporate compliance program.
• Monitor changes in healthcare regulations and collaborate with the appropriate stakeholders to assess organizational impact.
• Partner with the appropriate internal stakeholders to ensure compliance with applicable laws, standards and contractual commitments.
• Assist in risk assessments and compliance program effectiveness evaluations.
• Maintain and update policies, procedures, and compliance documentation.

Internal Audits & Audit Readiness

• Support the execution of client audits and audit readiness activities includes providing guidance to internal stakeholders on oversight audit design and execution.
• Develop audit tools and methodologies consistent with industry best practices and regulatory/accreditation requirements.
• Evaluate compliance with regulatory standards such as CMS, state DOI, URAC and NCQA where applicable.
• Document audit findings, identify root causes and provide actionable recommendations.
• Collaborate with internal and external stakeholders to manage corrective action plans (CAPs) through closure.
• Maintain audit schedules and ensure timely completion of all oversight activities.
• Conduct internal audits across functional areas (i.e. operations, clinical programs, HR/HCM, IT/Information Security).
• Perform ongoing monitoring activities to identify compliance risks and trends.
• Prepare comprehensive audit reports and present findings to internal stakeholders and leadership.
• Support enterprise risk management initiatives as needed.

Utilization Review / PBM Licensure & Regulatory Filings

• Prepare and submit initial, renewal, and amendment filings for Utilization Review (UR) licenses across all applicable state jurisdictions, ensuring accuracy, completeness, and compliance with varying regulatory requirements and deadlines.
• Demonstrate strong knowledge of UR licensure requirements, including applicability by line of business, and interpret state-specific URA regulations to ensure compliant filings.
• Validate filings against applicable states, CMS, URAC, and NCQA accreditation standards.
• Maintain compliance calendars and serve as primary liaison with state regulatory agencies and licensing bodies.
• Monitor and respond to state regulator inquiries, deficiency notices, and documentation requests.
• Evaluate entity structure changes (e.g., name changes, EIN changes, ownership changes) for licensure impact and required filings.
• Support and respond to external audits.
• Conduct 50-state regulatory research to identify licensure requirements, applicability, and compliance obligations.
• Maintain and update state-specific Utilization Management (UM) policies and procedures, ensuring alignment with regulatory requirements and operational practices.

Training & Education

• Assist in developing and delivering compliance training programs.
• Promote a culture of compliance and ethical conduct throughout the organization through compliance communications and presentations.
• Coordinate the collection, validation, and reporting of statistical data required for licensure filings, audits, and regulatory reporting.
• Other Duties: Perform additional tasks as assigned.

QUALIFICATIONS

Required: [minimum education, certifications, and experience needed]

• Requires a BA/BS and minimum of 5 years health care, regulatory, ethics, auditing, compliance or privacy experience; or any combination of education and experience, which would provide an equivalent background.
• Experience with managed care, utilization management, care management, PBM or health plan environments.
• Experience managing multi-state licensure processes (UR/PBM).
• Capable of working within tight deadlines and the ability to arrange timeline properly.
• Demonstrated experience with regulatory audits and delegated oversight programs.
• Detail-oriented and highly organized.
• Strong analytical capability, audit experience and deep understanding of healthcare regulatory frameworks in the US.
• Knowledge of UR and PBM regulatory requirements across multiple states.
• Demonstrated audit expertise including planning, execution and reporting.
• Ability to interpret complex regulations and translate into actionable guidance.
• Effective communication skills (verbal and written).
• Proficient in MS Office Applications, PDF, Office 360.
• Strong written and verbal communication skills including executive-level reporting.
• Able to do problem-solving functions.
• Strong moral and ethical principles with high level of integrity, discretion and professional judgement.

Desired: [preferred qualifications that enhance performance but are not mandatory]

• Regulatory compliance and/or legal experience preferred.
• Medicare, Medicaid, and/or Commercial experience preferred.
• Certified in Healthcare Compliance, Internal Auditor or related healthcare certifications preferred.
• Previous global, matrixed healthcare organization experience/background preferred.

Success Measures

• Timely and accurate licensure submissions and renewals.
• Completion of audit plans with high-quality outcomes.
• Effective closure of corrective action plans.
• Positive regulatory and client audit outcomes.
• Reduction in compliance risks and audit findings over time.

Work Logistics

• Full-time, remote role. Headquarters in Nashville, TN. Occasional travel to headquarters office may be required.