Associate Medical Director, Regulatory Management

Hi, we're the company. We're hiring an Associate Medical Director, Regulatory Management to join our Clinical Affairs team.

The company is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started the company in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

The Associate Medical Director, Regulatory Management provides strategic and operational leadership for provider clinical regulatory programs and credentialing operations. This role drives clinical policy guidance, ensures enterprise compliance with NCQA, CMS, state, and accreditation standards, and leads continuous process improvement. Partnering cross-functionally across Quality, Network Management, and Compliance, this leader optimizes provider onboarding to deliver a high-quality, compliant network that supports member access and organizational growth.

Work Location: This position is fully remote and open to candidates residing in the U.S., excluding Alaska; Delaware; Hawaii; Louisiana; Montana; North Dakota; Oklahoma; West Virginia; Wyoming; and U.S. Territories. Daily work is completed from your home office, with occasional travel required for team meetings and company events. #LI-Remote

Pay Transparency:  The base pay for this role is: $216,108 - $283,642 per year. You are also eligible for employee benefits, participation in the company's unlimited vacation program and annual performance bonuses.

Responsibilities

• Build and lead the Clinical Policy Compliance team and the Clinical Coding Center of Excellence, driving high-impact compliance, quality, and regulatory strategy across the organization.

• Direct the development of clinical regulatory policies, Benefit Interpretation Policies (BIPs), and operational SOPs to ensure full alignment with state and federal laws, in partnership with other SMEs in the Office of Clinical Affairs.

• Chair the Credentialing, Peer Review, and Population Health Management sub-committee, driving individual case reviews and reporting key performance metrics to quarterly Quality Improvement meetings.

• Oversee practitioner and facility credentialing to guarantee compliance with NCQA standards, CMS requirements, and state regulations - verifying licenses, board certifications, and sanction histories.

• Partner with Network and Market Management executives to accelerate provider onboarding and strategically resolve network gaps while maintaining strict credentialing integrity.

• Collaborate on Quality Improvement for Clinical Review Operations, optimizing Inter-Rater Reliability (IRR) processes, clinical delegate audits, and Potential Quality Issue (PQI) workflows.

• Identify and resolve operational bottlenecks to streamline processes, eliminate delays, and enhance member and provider satisfaction without compromising quality or compliance.

• Serve as a subject matter expert on state and federal healthcare regulations, continuously monitoring legal developments and translating regulatory changes into proactive operational updates to maintain ongoing compliance.

• Compliance with all applicable laws and regulations.

• Other duties as assigned.

Requirements

• 7+ years of progressive healthcare experience, including leadership responsibility.

• 3+ years experience managing provider credentialing within a health plan, managed care organization, or large healthcare system.

• 3+ years knowledge of NCQA credentialing standards, CMS health plan regulatory requirements, and applicable federal and state regulations.

• 1+ years experience managing and working with clinical coding taxonomies.

• Demonstrated experience leading operational improvement initiatives and managing cross-functional partnerships.

• Strong knowledge of provider data management, credentialing systems, and primary source verification processes.

• Proven ability to lead teams, manage competing priorities, and lead measurable operational results.

• Education:

• MD or DO with a current unrestricted license to practice medicine is required.

License and Certification

• Reviewers must maintain necessary credentials to retain the position including maintaining active board certification.

• Willing to obtain additional state licensure (with the company's support).

Bonus points

• Licensure in multiple the company states.

• Masters degree or advanced certificate.

• Prior experience with Utilization management.

This is an authentic the company job opportunity.

At the company, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.

Pay Transparency:  Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.

Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts.

Reasonable Accommodation: the company applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any the company applicant who requires reasonable accommodations during the application process should contact the company Benefits Team [link for members] to make the need for an accommodation known.

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