Sr. Compliance Specialist - Payment Integrity

Vālenz ® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible. About This Opportunity: As a Sr. Compliance Specialist - Payment Integrity (aka Sr. Product Compliance Specialist - Payment Integrity), you'll support Payment Integrity and Payment Operations as the primary compliance lead for regulatory requirements impacting claims, billing, reimbursement, and payment activities. You'll provide risk-based compliance oversight for areas including the No Surprises Act (NSA), Fraud, Waste & Abuse (FWA), regulatory change management, operational initiatives, and other payment-related processes. You'll partner closely with Product, Operations, and Corporate Compliance teams to support policy governance, compliance training, issue intake management, and ongoing efforts to ensure compliance with applicable state and federal regulations. Things You’ll Do Here : Serve as the primary compliance liaison for Payment Integrity and Payment Operations, providing strategic guidance on regulatory and operational compliance matters. Interpret, analyze, and operationalize applicable regulatory requirements, including the No Surprises Act (NSA), Fraud, Waste & Abuse (FWA) laws, CMS requirements, and state Department of Insurance (DOI) regulations impacting payment and billing practices. Provide compliance oversight and guidance related to payment workflows, reimbursement methodologies, claims administration processes, and product development initiatives. Partner cross-functionally with operational leaders to identify, assess, and mitigate financial and regulatory compliance risks associated with payment and claims functions. Monitor and evaluate emerging regulatory developments, enforcement trends, and industry guidance to determine operational impact and support implementation of required changes. Support the development, review, implementation, and maintenance of financial and payment-related policies, procedures, and standard operating procedures (SOPs). Participate in high-risk initiatives, system implementations, process enhancements, and product changes to ensure compliance considerations are appropriately addressed. Assist with incident response activities involving payment disputes, FWA-related escalations, regulatory inquiries, and other compliance-related matters. Support internal audits, external audits, client audits, and regulatory examinations by coordinating documentation, responding to inquiries, and ensuring audit readiness. Collaborate with Corporate Compliance and cross-functional stakeholders on issue intake, triage, investigation support, tracking, corrective action planning, and resolution activities. Develop and deliver training, education, and compliance guidance to internal stakeholders regarding applicable regulatory requirements, policies, and operational expectations. Maintain accurate and organized documentation supporting compliance oversight activities, monitoring efforts, investigations, and audit preparedness. Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties. What You’ll Bring to the Team : Bachelor’s degree required; concentration in Healthcare Administration, Finance, Business Administration, or a related field preferred. 5+ years of progressive experience in healthcare compliance, payment integrity, regulatory compliance, or related healthcare operations. Certified Professional Coder (CPC) credential or equivalent coding certification. Demonstrated knowledge and experience with claims processing operations and/or payment integrity programs. Demonstrated knowledge of healthcare billing, coding, and reimbursement regulations. Demonstrated experience with Fraud, Waste & Abuse (FWA) compliance frameworks and investigative processes A plus if you have… Experience supporting No Surprises Act (NSA) implementation, oversight, and compliance activities. Experience within Payment Integrity, health plan, payer-side, or managed care operations. Familiarity with CMS programs, regulatory requirements, and enforcement priorities impacting claims and payment oversight. Experience operating within a Business Associate environment and supporting HIPAA-related compliance obligations. Professional certifications such as Certified in Healthcare Compliance (CHC), Certified Fraud Examiner (CFE), CPC, or other relevant healthcare compliance credentials. About This Opportunity: As a Sr. Product Compliance Specialist - Care (aka Sr. Compliance Specialist - Care Management Programs), you'll partner with Care Management and Utilization Management teams as the primary compliance resource for regulatory, accreditation, and licensing requirements impacting clinical operations. You'll provide risk-based compliance oversight for areas including CMS regulations, NCQA and URAC standards, multi-state UM licensing requirements, regulatory change management, and other operational initiatives. You'll work closely with Product, Operations, and Corporate Compliance teams to support policy governance, compliance training, issue intake management, and ongoing efforts to ensure compliance with applicable regulatory and accreditation requirements. Things You’ll Do Here : Serve as the primary compliance liaison for Care Management and Utilization Management operations, providing strategic guidance and oversight to ensure adherence to applicable regulatory and accreditation requirements. Interpret, assess, and operationalize regulatory standards, including CMS Medicare Advantage and Managed Care requirements, NCQA and URAC accreditation standards, Utilization Review and Utilization Management regulations, and 42 CFR Part 2 requirements, as applicable. Oversee and support the organization’s multi-state Utilization Management licensing program by tracking licensing requirements across applicable jurisdictions, coordinating license applications and renewals, maintaining supporting documentation, and partnering with operational leaders to ensure ongoing compliance with licensing conditions and regulatory obligations. Provide compliance guidance and subject matter expertise related to clinical workflows, operational processes, policy development, and system implementations impacting Care operations. Support the full lifecycle management of Care-related policies, standard operating procedures, and associated documentation. Monitor regulatory developments and emerging compliance requirements, evaluate operational impact, and communicate relevant updates and recommendations to key stakeholders. Participate in high-risk initiatives, operational enhancements, and product or process changes to ensure compliance considerations are appropriately addressed. Support organizational readiness for audits, regulatory reviews, and accreditation activities, including NCQA and URAC surveys. Assist with incident response activities involving Care operations, including privacy-related inquiries, compliance investigations, and regulatory escalations. Collaborate with Corporate Compliance and cross-functional teams on issue intake, triage, tracking, remediation, and resolution efforts. Provide education, training, and ongoing guidance to internal stakeholders regarding applicable regulatory and compliance requirements. Maintain accurate and organized documentation to support compliance activities, regulatory inquiries, audits, and accreditation requirements. Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties. What You’ll Bring to the Team : Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or a related field. 5+ years of experience in healthcare compliance, regulatory affairs, clinical operations, or a related healthcare environment. Demonstrated experience supporting Utilization Management, Care Management, and/or Disease Management programs. Working knowledge of CMS regulatory frameworks and managed care compliance requirements. Experience with NCQA and/or URAC accreditation standards and related operational readiness activities. Strong understanding of multi-state healthcare regulatory and compliance environments. A plus if you have… Experience managing or supporting multi-state Utilization Management licensure programs. Clinical background, such as Registered Nurse (RN) or equivalent clinical experience. Knowledge of 42 CFR Part 2 requirements and related privacy regulations. Experience operating within a Business Associate environment. Relevant professional certification preferred, such as Certified in Healthcare Compliance (CHC), Certified Professional in Healthcare Quality (CPHQ), or equivalent. Where You’ll Work: This is a fully remote position, and we’ll provide all the necessary equipment! Work Environment: You’ll need a quiet workspace that is free from distractions. Technology: Reliable internet connection—if you can use streaming services, you’re good to go! Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software. Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA. Why You'll Love Working Here Valenz is proud to be recognized by Inc. 5000 as one of America’s fastest-growing private companies. Our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare . With this commitment, you’ll find an engaged culture – one that stands strong, vigorous, and healthy in all we do. Benefits Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card. Spending account options: HSA, FSA, and DCFSA 401K with company match and immediate vesting Flexible working environment Generous Paid Time Off to include vacation, sick leave, and paid holidays Employee Assistance Program that includes professional counseling, referrals, and additional services Paid maternity and paternity leave Pet insurance Employee discounts on phone plans, car rentals and computers Community giveback opportunities, including paid time off for philanthropic endeavors At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products. Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.