We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

Responsible for directing compliance across provider network operations, ensuring adherence to current regulations while leading the implementation of new regulatory requirements and accreditation standards. Leads provider network regulatory audits, reporting, and responses to requests for information (RFIs). Oversees provider network policies, procedures, and TRICARE certification processes. Develops and manages compliance metrics and KPIs to monitor performance and drive accountability. Leads the development and execution of provider network corrective action plans and audit responses to mitigate risk and ensure sustained compliance. Directs provider network vendor management, ensuring performance and regulatory expectations are met. Serves as a trusted advisor and subject matter expert to leadership on provider network compliance matters. Partners cross-functionally to support provider education initiatives to strengthen compliance and operational effectiveness.

Education & Experience

Required:

• Bachelor's degree in business administration, healthcare administration, or related field or equivalent experience
• U.S. Citizen • Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 5 years of experience in a managed care or payer environment
• 5+ years of progressively responsible people management experience to include managing leaders in the healthcare industry
• Minimum of 3 years of experience managing URAC, NCQA, or other equivalent accreditation standards
• Experience in strategic planning, program design and management, and team leadership with a focus on leadership and staff development

Preferred:

• Experience leading compliance oversight for provider network operations
• Experience in government healthcare delivery programs, such as Veterans Affairs, TRICARE, or Medicare

Key Responsibilities

• Directs and oversees compliance across provider network operations, ensuring adherence to all applicable federal, state, and regulatory requirements as well as accreditation standards (e.g., URAC, NCQA).
• Leads the implementation and operationalization of new and evolving regulatory requirements, ensuring timely integration into provider network processes, policies, and systems.
• Oversees and manages provider network regulatory audits, including planning, execution, documentation, and coordination of responses to regulatory inquiries and RFIs.
• Provides oversight to establish, maintain, and continuously improve provider network policies, procedures, and governance frameworks, driving standardization and ensuring consistent alignment with federal, state, and accreditation requirements.
• Directs TRICARE certification processes, ensuring network providers consistently meet compliance and eligibility standards.
• Develops, tracks, and reports on compliance metrics and key performance indicators (KPIs) to monitor effectiveness, identify risks, and drive accountability across provider network operations. • Leads the development, submission, and ongoing monitoring of responses and corrective action plans (CAPs) for internal and external audit findings, ensuring timely resolution, effective risk mitigation, and sustained compliance.
• Oversees and directs provider network vendor management from a compliance perspective, ensuring contracted partners meet contractual, regulatory, performance, and service delivery expectations.
• Serves as a strategic advisor and subject matter expert to senior leadership on provider network compliance, translating complex regulatory requirements into actionable strategies and providing insight on emerging risks, trends, and effective mitigation approaches.
• Partners cross-functionally with Provider Services, Compliance, Legal, IT, and other operational areas to support compliance initiatives and strengthen overall network performance.
• Leads provider education and training initiatives to promote regulatory awareness, strengthen compliance adherence, and enhance provider engagement.
• Develops and delivers executive-level compliance reports and dashboards that provide visibility into provider network performance, regulatory adherence, audit outcomes, and emerging risk trends for senior leadership and key stakeholders. • Develops and implements strategic staffing and resource plans to meet evolving provider network compliance needs. Recruits, onboards, trains, coaches, and develops a high-performing, accountable team while promoting continuous professional growth.
• Evaluates and defines funding and resource requirements, developing annual business cases to support recommendations. Forecasts future needs by analyzing industry trends and aligning resource planning with organizational objectives and strategic priorities.
• Maintains regular and reliable attendance and demonstrates leadership that reflects organizational values and commitment to service excellence.

Competencies

Coaching / Training / Mentoring: Drives desired business outcomes by delivering continuous, targeted coaching, training, and mentorship; provides timely, actionable feedback, builds team capabilities, and fosters a culture of accountability, learning, and performance excellence.

Communication / People Skills: Influences and persuades stakeholders across diverse and challenging situations by adapting communication styles, demonstrating active and critical listening, and fostering collaborative partnerships to achieve aligned, compliant outcomes.

Computer Literacy: Demonstrates advanced proficiency in a multi-system Microsoft environment and internal platforms, including the TriWest Intranet, internet-based tools, and department-specific applications; leverages technology effectively to manage workflows, ensure data accuracy, and support compliant, efficient operations.

Coping / Flexibility: Demonstrates composure and effectiveness in dynamic, high-pressure environments by adapting to diverse situations and stakeholders; maintains focus on organizational objectives while applying sound judgment, mature problem-solving, and a solutions-oriented mindset.

Empathy / Customer Service: Champions a customer-centric approach by demonstrating active listening, patience, respect, and genuine empathy for diverse perspectives; builds trust, resolves concerns effectively, and ensures responsive, service-oriented interactions aligned with organizational and compliance standards.

Independent Thinking / Self-Initiative: Applies critical thinking to prioritize high-impact work and drive results with minimal direction; demonstrates ownership and accountability by proactively identifying solutions, securing necessary resources, and following through to achieve outcomes aligned with organizational and compliance objectives.

Information Management: Effectively synthesizes and manages large volumes of complex data, translating insights into clear, actionable communication; uses analytical rigor and sound judgment to draw accurate conclusions, inform decision-making, and ensure compliance with regulatory requirements and accreditation standards.

Leadership: Effectively leads a diverse workforce by adapting management approaches to individual styles and needs; provides clear direction, sets performance expectations, and delivers consistent coaching and feedback to drive engagement, accountability, and high performance.

Multi-Tasking / Time Management: Effectively prioritizes and executes multiple initiatives in a high-volume, fast-paced environment; adapts to shifting deadlines and competing demands while maintaining focus, quality, and compliance with organizational standards.

Problem Solving / Analysis: Applies structured, analytical problem-solving to evaluate processes, identify root causes, and implement effective solutions, demonstrating sound judgment and a practical understanding of operational and compliance-related issues.

Team-Building / Team Player: Cultivates a collaborative, high-performing team environment by positively influencing others, aligning diverse perspectives, and building strong commitment to shared goals and compliance objectives.

Technical Skills: Demonstrates comprehensive knowledge of state and federal regulatory requirements and accreditation standards (e.g., URAC, NCQA), ensuring full compliance across provider network operations; applies deep expertise in provider network compliance principles, practices, policies, and procedures to guide strategic and operational initiatives; leads program development and drives process optimization through the application of continuous improvement methodologies to enhance efficiency, quality, and regulatory adherence; utilizes advanced proficiency in Microsoft Office Suite and enterprise systems to analyze data, support decision-making, and strengthen provider network performance and compliance oversight.

Working Conditions

Working Conditions:

• Availability to cover any work shift as needed
• Travel may be required
• May work within a standard office environment
• Extensive time utilizing a computer with prolonged sitting
• Must be able to obtain appropriate security clearance

Company Overview

Taking Care of Our Nation's Heroes.

It's Who We Are. It's What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®!

Our job is to make sure that America's heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996.

DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Benefits

We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $160, 000 to $169, 000 per year.

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.