Senior Director, Regulatory Affairs & Delegated Services | NantHealth

NantHealth is adding a Senior Director of Regulatory Affairs & Delegated Services to our Eviti leadership team. In this role, you're responsible for the regulatory strategy, compliance oversight, and operational integrity of delegated services supporting Eviti solutions. You'll lead the design, implementation, and ongoing oversight of programs that ensure compliance with Medicare, Medicaid, Commercial, and state-specific regulatory requirements, with particular emphasis on audit readiness, delegated utilization management, denials, appeals, grievances, and physician licensing oversight. The ideal candidate brings deep experience in full delegation models and has successfully led organizations through health plan, CMS, and state-level audits. You're able to interpret complex and evolving regulations, translate them into scalable operational requirements, and partner across compliance, legal, clinical, operational, and technology teams to ensure delegated workflows are compliant, defensible, and audit-ready. We're seeking a highly experienced regulatory and delegated operations leader who has personally managed complex audits, understands Medicare and multi-state regulatory requirements in depth, and can translate compliance obligations into effective technical and operational workflows. This position offers the flexibility to work remotely within the United States, and requires the ability to travel, up to 15%. Responsibilities include, but are not limited to: 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. Provide regulatory leadership for Medicaid delegated services, including interpretation of state-specific Medicaid and managed Medicaid requirements and coordination with plan-specific 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. Support development and maintenance of policies and procedures aligned with applicable regulatory and accreditation standards, including CMS, NCQA, URAC, and payer-specific delegation standards. Serve as a key point of contact with external health plan partners, auditors, regulators, and accreditation entities related to delegated compliance activities. Education & Experience 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. Required Knowledge, Skills, and Abilities: 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. Additionally beneficial skills, certifications, etc. Experience in oncology, specialty utilization management, or specialty benefit management. Experience working within a delegated vendor, health plan, MSO, IPA, or other complex managed care environment. Familiarity with NCQA, URAC, and delegation oversight frameworks. Experience building or enhancing technical and operational workflows for denials, appeals, grievances, and utilization management functions. Experience in rapidly scaling, multi-state healthcare operations. Working knowledge of commercial and state-regulated delegated service requirements. Relatable license and / or certifications including: CPHQ, CHC, RN, JD What success looks like... Delegated services are consistently audit-ready and supported by clear documentation, controls, and monitoring. State-specific regulatory and licensing requirements are proactively tracked and operationalized across all applicable markets. Denials, appeals, and grievances workflows are compliant, well-designed, measurable, and scalable. Audit findings and compliance risks are identified early and addressed through sustainable corrective actions. Health plan and regulatory partners view Eviti as a credible, disciplined, and reliable delegated entity.   The salary range for applicable US-based applicants to this position is below.  The specific rate will depend on the successful candidate’s qualifications, prior experience as well as geographic location.   $135,000 - $175,000 base salary plus bonus potential.