Senior Director, Regulatory Affairs & Delegated Services | NantHealth

Responsibilities

• Lead regulatory strategy, governance, and oversight for delegated services across Medicare, Medicaid, and Commercial lines of business, ensuring alignment with federal, state, payer, and contractual requirements.
• Serve as the subject matter expert on full delegation requirements, including delegated utilization management, clinical decision-making oversight, denials, appeals, grievances, and related reporting obligations.
• Own enterprise audit readiness for delegated UM functions, including CMS audits, health plan delegation audits, state regulatory reviews, mock audits, gap assessments, tracer development, documentation reviews, and remediation planning.
• Lead development, execution, and monitoring of corrective action plans, ensuring root cause analysis, sustainable remediation, and ongoing performance monitoring.
• Interpret and operationalize delegated contractual obligations and state-specific regulatory requirements, including utilization management rules, notice requirements, turnaround times, physician reviewer requirements, member protections, and delegation oversight expectations to ensure operational alignment, compliance governance, and audit defensibility.
• Establish and maintain a state-by-state regulatory framework, including compliance matrices, workflow requirements, regulatory monitoring systems, and control structure to support multi-state delegated operations.
• Develop regulatory risk escalation pathways, governance structures, and remediation strategies for identified compliance vulnerabilities across delegated operations.
• Oversee physician licensing compliance for medical directors, peer reviewers, and other clinical staff performing delegated functions, ensuring appropriate state licensure, renewal tracking, exclusions monitoring, and compliance with state-specific reviewer requirements.
• Ensure delegated services are structured to comply with federal, state, contractual, and accreditation standards, including coverage determination, appeal, grievance, timeliness, documentation, and oversight expectations.
• Partner with operations and technology teams to assess, design, and improve technical workflows that support delegated denials, appeals, and grievances processes, including intake, case routing, escalation paths, notices, queue management, documentation, audit trails, and reporting.
• Ensure delegated workflows support accurate decision-making, timely processing, complete documentation, and defensible audit outcomes.
• Collaborate with legal, compliance, and business leaders on delegation-related contract language, oversight models, and risk mitigation strategies.
• Monitor, interpret, and operationalize changes in CMS, state, and payer requirements, including enterprise impact assessment and translate those changes into policies, procedures, system requirements, and operational controls.
• Monitor, interpret, and communicate emerging legislative, regulatory, and policy developments across federal, state, payer, and delegated environments, proactively assessing organizational impact and guide strategic readiness.
• Serve as a key point of contact with external health plan partners, auditors, regulators, and accreditation entities related to delegated compliance activities.

Requirements

• 10+ years of progressive leadership experience in healthcare regulatory affairs, delegated services oversight, compliance, or managed care operations.
• Significant hands-on experience leading and managing audits, including CMS audits, payer delegation audits, and/or state regulatory reviews.
• Proven success building and sustaining audit-ready delegated programs, including corrective action planning and remediation management.
• Direct experience overseeing or partnering closely on denials, appeals, and grievances operations in a delegated or payer environment.
• Experience with physician licensing compliance across multiple states, including oversight of licensure verification, renewals, and state-specific reviewer qualifications.

Qualifications

• Strong working knowledge of Medicaid regulatory requirements, including multi-state Medicaid or managed Medicaid experience.
• Demonstrated expertise in interpreting and applying state-specific healthcare regulations affecting utilization management, delegated operations, and clinical review functions.
• Deep expertise in Medicare within delegated UM/payer operations, including Medicare Advantage regulatory requirements, audit expectations, and delegated oversight models.
• Ability to translate regulatory and contractual requirements into practical workflows, policies, controls, reporting structures, and system requirements.
• Strong cross-functional leadership skills with experience partnering across compliance, legal, clinical, operations, and technology teams.
• Excellent executive communication skills and the ability to work effectively with internal leadership and external payer partners.

Benefits

NantHealth provides a comprehensive benefits package including:

• Robust medical, dental, and vision insurance
• Financial planning assistance
• Physical and mental wellness discounts, including an optional annual subscription to the Headspace app and unlimited access to our online learning platform
• Paid time off (hourly) / flex time off (salaried) programs for Full Time employees
• Growth and Development opportunities
• 401(k), including a 3% company match
• Paid holidays
• Paid parental leave, including a flexible return-to-work program
• Employee Assistance Program
• Discounts on popular cell phone plan providers
• Life & disability insurance
• Travel assistance
• Education assistance program
• And much more!

We value each of our employee’s total wellness and provide equal employment opportunities to all employees and applicants for employment without discrimination based on race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.