Assistant Director Clinical Regulatory Operations

About the Role

Join our Cause to create a person-focused and economically sustainable health care system. As a member of the Transformation, Quality, and Learning team, our Assistant Director Clinical Regulatory Operations leads a clinical regulatory operations team that serves as a strategic partner to HSO clinical business leaders — enabling the pursuit of improved affordability, operational efficiency, quality, and member experience within a framework of regulatory compliance.

Responsibilities

• Partners with Regulatory Affairs, Quality, Legal, Compliance, and clinical business owners to identify, interpret, and operationalize new and evolving regulatory requirements across all HSO program areas (Utilization Management & Appeals, Care Management, Pharmacy, Payment Integrity).
• Serves as a strategic partner to HSO clinical leaders, enabling improved affordability, operational efficiency, quality, and member experience within regulatory guardrails.
• Facilitates operational simplification by systematically comparing and aligning processes across teams and lines of business—standardizing where appropriate to reduce redundancy, scale consistent compliance practices, and streamline operations using improvement science methodologies.
• Designs and executes regulatory compliance programs using structured improvement models (PDSA, Lean, Six Sigma) to drive program maturity and advance operations toward embedded operational excellence.
• Establishes and continuously improves audit and monitoring processes, incorporating automation, dashboards, and real-time reporting in partnership with data, analytics, and technology teams.
• Manages corrective action plans from internal monitoring, external audits, and accreditation surveys—applying root cause analysis to address systemic drivers and ensure sustainable remediation.
• Collaborates with Cambia Regulatory stakeholders to identify emerging compliance trends, detect risk areas, and recommend proactive mitigation strategies.
• Leads NCQA accreditation readiness activities including gap assessments, mock audits, and submission preparation.
• Oversees the HSO Rapid Resolution Team managing complex member escalation cases with systematic root cause analysis and trend monitoring.
• Oversees the Clinical Review Inter-rater Reliability program ensuring evidence-based, objective reviews with structured calibration processes, statistically valid sampling, and performance benchmarks aligned with NCQA, URAC, and industry best practices.
• Handles all management responsibilities including performance reviews, development, hiring, coaching, and retention.
• Manages department budget, authorizes expenditures, monitors workforce allocation, and oversees project plans.
• Establishes long-term department goals in conjunction with division leadership and acts as liaison between HSO program areas and enterprise stakeholders.

Qualifications

• Bachelor's degree in Healthcare Administration, Nursing, Public Health, or a related field (Master's preferred)
• 5 years of leadership experience
• 7 years of health insurance or managed care experience focused on regulatory compliance, quality management, or clinical operations — or an equivalent combination of education and experience

Skills

• Demonstrated knowledge of CMS, state, NCQA, HIPAA/Privacy, and managed care contract compliance requirements as applied across Utilization Management & Appeals, Care Management, Pharmacy, and Payment Integrity.
• Ability to interpret complex regulatory requirements and translate them into clear, actionable operational guidance for diverse audiences.
• Demonstrated competency in designing and executing compliance monitoring, auditing, and reporting programs in a health plan or managed care environment.
• Demonstrated knowledge and application of improvement science methodologies (e.g., PDSA, Lean, Six Sigma), with the ability to drive operational improvement beyond compliance monitoring.
• Demonstrated ability to analyze and align operational processes across multiple teams and lines of business to achieve standardization, simplification, and scalability.
• Experience leading cross-functional regulatory implementation efforts in collaboration with clinical operations, legal, compliance, and regulatory affairs.
• Ability to identify compliance gaps, conduct root cause analysis, and lead data-driven remediation across operational teams.
• Experience leveraging automation, data analytics, and technology to enhance compliance monitoring and program effectiveness; familiarity with dashboard development or workflow automation preferred.
• Demonstrated competency in resource and project management, including budgeting, workforce planning, and managing to deliverables.
• Ability to develop and lead teams across multiple locations or remote environments, including hiring, goal setting, coaching, and development.
• Strong written and verbal communication skills, including regulatory memos, executive reporting, and presentations.
• Experience writing policies and procedures and developing monitoring and auditing tools.
• Experience with AI tools and technologies to enhance productivity and decision-making highly desired.

Location and Schedule

Hybrid role (3 days/week in office) at our Burlington, Renton, Spokane, Vancouver, Portland, Medford, Salt Lake City, Boise, Lewiston, Fargo offices. Candidates must reside within commutable distance of that location or be willing to relocate.

Pay

Pay ranges vary based on the candidate's work location. The expected hiring range depends on skills, experience, education, and training; relevant licensure / certifications; and performance history.

• Oregon, Washington, Utah, and Idaho: The expected hiring range is $136,000 - $184,000, the full salary range is $128,000 - $208,000 and the bonus target is 20%.
• North Dakota: The expected hiring range is $128,144.30 - $173,371.70, the full salary range is $113,780 - $187,737 and the bonus target is 15%.

About Cambia

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care.

Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.