• Conduct structured compliance reviews of federal healthcare contract requirements, modifications, manuals, deliverables, workflows, desk procedures, system outputs, and operational documentation. • Analyze how contract requirements are interpreted and executed across business processes, systems, reporting structures, and functional teams. • Develop contractual crosswalks that align requirements, source documentation, operational execution, evidence reviewed, identified gaps, and recommended actions. • Evaluate federal healthcare program operations to identify compliance risk, performance risk, interpretation inconsistencies, documentation gaps, and areas where execution may not align with contractual intent. • Review contract modifications, policy updates, procedural changes, and related documentation to assess operational impact and implementation requirements. • Prepare concise executive summaries, detailed findings, contractual crosswalks, risk assessments, and recommendation documents for senior leadership and program stakeholders.

• Conduct thorough online research (OSINT) to verify corporate entities, locate key personnel, and track down accurate contact information. • Review technical and company data (IPs, domains, usage logs) to identify and document potential software misuse. • Perform high-volume, highly accurate data entry to keep our CRM system organized and up to date. • Compile gathered data into clear, well-structured spreadsheets and reports for the broader team. • Work closely with experienced teammates to move cases forward efficiently. • Learn new search techniques and help improve our data collection processes.

• 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.

• 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.