Compliance Specialist/ Delegation Oversight

Position Purpose : The Compliance Specialist / Delegation Oversight supports Doctors HealthCare Plans, Inc. (DHCP) in monitoring delegated entities and internal business areas for compliance with Medicare Advantage, Part D, D-SNP, contractual, regulatory, and DHCP requirements. The position performs routine and risk-based oversight, validates corrective actions, supports CMS Program Audit readiness, and completes compliance projects and other assignments as needed. The role provides compliance oversight.

Key Responsibilities:

• Conduct routine, focused, and risk-based monitoring of delegated entities in accordance with DHCP’s delegation oversight program, contracts, policies, and applicable CMS requirements.

• Review delegate policies, procedures, workflows, reports, notices, system configurations, and supporting documentation to assess compliance and operational alignment.

• Monitor delegate performance against established requirements, service-level expectations, reporting obligations, and corrective action commitments.

• Coordinate and document delegate oversight activities, including pre-delegation reviews, annual assessments, monitoring reviews, audits, validation testing, and follow-up activities.

• Identify potential deficiencies, document findings clearly, communicate required remediation, and track corrective action plans through validated closure.

• Maintain complete, organized, and audit-ready records of oversight activities, evidence reviewed, findings, communications, corrective actions, and closure determinations.

• Escalate material, repeated, overdue, or high-risk issues to Compliance leadership and appropriate business owners in a timely manner.

• Partner with operational areas, delegates, vendors, and subject-matter experts to resolve compliance questions while maintaining appropriate independence and oversight boundaries.

• Support regulatory inquiries, internal audits, external audits, CMS Program Audits, and other oversight activities by gathering, validating, and organizing requested documentation.

• Assist with compliance reporting, committee materials, dashboards, risk assessments, issue logs, and management updates.

• Lead or support compliance projects, workgroups, monitoring initiatives, policy updates, regulatory implementations, and audit-readiness activities as assigned.

• Complete special projects and ad hoc analyses based on emerging compliance risks, regulatory changes, business needs, audit results, or direction from Compliance leadership.

• Develop project plans, trackers, timelines, status reports, and supporting documentation when assigned responsibility for a project or workstream.

• Coordinate with responsible business leaders and delegates to obtain deliverables, monitor due dates, identify barriers, and escalate delays or risks.

• Assist with training, guidance, tools, templates, and communications related to assigned compliance initiatives.

• Perform other compliance, delegation oversight, and departmental duties as assigned or as needed to support DHCP’s Compliance Program.

Qualifications:

• Working knowledge of Medicare Advantage and Part D compliance requirements and CMS audit protocols is preferred.

• Ability to review operational processes and supporting evidence, identify compliance gaps, and communicate findings in clear, professional language.

• Strong organizational, documentation, analytical, and follow-up skills, including the ability to manage multiple assignments and deadlines.

• Ability to exercise sound judgment, maintain confidentiality, and escalate issues appropriately.

• Proficiency with Microsoft Word, Excel, PowerPoint, Outlook, Teams, Monday and SharePoint; experience with compliance tracking, claims, utilization management, or delegated oversight systems is preferred.

• Effective written and verbal communication skills and the ability to work collaboratively with internal departments, delegates, vendors, and leadership.

• Bachelor’s degree in health care administration, business, compliance, or a related field preferred; relevant experience may be considered in place of a degree.

• Three or more years of experience in health plan operations, Medicare compliance, delegated entity oversight, auditing, utilization management, claims, appeals and grievances, or a related regulated health care function preferred.

• Experience with CMS Program Audit universes, corrective action plans, or Medicare Advantage operational oversight is preferred.

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team meber(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

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