Compliance Manager

Job Description:- Monitor and analyze state and federal regulatory developments, legislation, and industry trends governing workers compensation affecting Rising's lines of business - Independently research, track, and assess regulatory impact on managed care, bill review, and timely pay operations - Communicate regulatory changes to internal teams and customers - Provide input and subject matter expertise in the development of corporate compliance training materials. - Support clinical operations to maintain and support URAC certification and reaccreditation. - Manage certified managed care programs (MPN/MCO), including state filings, renewals, amendments, and reporting - Serve as primary contact with state regulatory agencies regarding filings, audits, deficiencies, and inquiries - Lead implementation and rollout of customer managed care programs - Maintain historical archives and resource documentation for state filings and customer materials. - Provide support for state UR certification processes, including renewals and compliance monitoring, and URAC certification - Develop and maintain managed care resource materials for Rising state filings and customer worksite materials - Oversee the coordination of resources to ensure the ongoing effectiveness of the state managed care programs - Monitor state regulatory sources for provider suspensions, exclusions, arrests, and fraud‐related actions affecting workers' compensation participation - Direct validation of provider TIN/NPI data, ensure fraud flags are entered in Vision, and oversee timely alerts to bill review and utilization review teams when exposure is identified - Lead and manage the MPN Coordinator team, ensuring consistent application of MPN rules, compliance standards, and service expectations - Oversee provider compliance, including credentialing changes, suspensions, fraud monitoring, and continuity of care - Monitor workload distribution and completion of MPN scheduling tasks to ensure service level expectations are met - Provide coaching and performance oversight to support timely, accurate responses to MPN requests from injured workers, customers, adjusters, and attorneys - Review geo‐access analysis and direct corrective actions to address network coverage gaps; serve as escalation point and backup responder as needed - Maintain regulatory documentation, dashboards, trackers, and compliance materials - Support RFP responses related to managed care, bill review, timely pay, and regulatory compliance - Manage cross-functional projects through planning, research, implementation, and audit review - Support maintenance of Business Continuity Plans and Disaster Recovery Plan and ensure their updates Requirements:- Bachelor' s degree in business administration or related field and ten (10) years significant business experience, or ten (10) years of industry experience - Significant experience in research and interpretation of Workers' Compensation state managed care plans and medical bill review requirements - Proven ability to manage multiple projects and deadlines in a regulated environment - Experience working with regulatory agencies, customers, and internal operational teams - Ability to interpret legislation and translate regulatory requirements into operational guidance - Excellent attention-to-detail, planning, and follow-through skills - Critical thinking and problem-solving skills - Must be a self-starter, flexible, customer-focused, and have a professional demeanor - Ability to work independently and as part of a team - Knowledge of industry regulations, terminology, principles, and practices; familiarity with legal reference materials, and thorough understanding of research techniques - Proficiency with Microsoft Office applications, SharePoint, Office 365 - Excellent oral and written communication skills - Excellent organizational/time management skills - Experience writing briefs and/or position papers Benefits:- Health insurance (4 different plans to choose from) - Dental - Vision - Paid time off (PTO) or Flexible Time Off (FTO) - 401(k) - Basic Life Insurance and Long-Term Disability Insurance (paid by the company) - Voluntary Life Insurance and Short-Term Disability Insurance - Flexible Spending Accounts (FSA) - Employee Assistance Program (EAP) - Rise Well Wellness Program - Professional Development Reimbursement Program (PDRP) - You will be part of our new Elevate program designed to recognize and reward employees for their hard work - We're on YouTube! Check out our culture at: http://www.youtube.com/user/RisingMedical - Want to see more? Check out our: - Facebook: https://www.facebook.com/RisingMedicalSolutions - LinkedIn: http://www.linkedin.com/company/rising-medical-sol..