Associate Medical Director, Regulatory Management
Core
Strategic and operational leadership for provider clinical regulatory programs and credentialing operations to ensure enterprise compliance and optimize provider onboarding.
Role type
Senior IC medical director (regulatory management)
Builds
Compliant provider networks and clinical policy frameworks
Domain
Health insurance / Healthcare regulation
Required skills
Provider credentialing management, NCQA standards expertise, CMS regulatory compliance, State/federal healthcare law knowledge, Clinical coding taxonomy management, Operational process improvement, Cross-functional partnership leadership, Provider data management, Primary source verification, Team leadership
Preferred skills
Utilization management experience, Multiple state licensure, Advanced degree (Masters)
Technologies
Credentialing systems, Primary source verification platforms
Responsibilities
Lead Clinical Policy Compliance team and Clinical Coding Center of Excellence; Develop clinical regulatory policies and Benefit Interpretation Policies; Chair Credentialing and Peer Review sub-committees; Oversee practitioner and facility credentialing; Partner on provider onboarding and network gap resolution; Optimize Quality Improvement workflows and Inter-Rater Reliability processes; Monitor legal developments and translate into operational updates.
Seniority
Senior, hands-on IC