[Hiring] Director of Value Based Care Regulatory Compliance @Agilon Health

Role Description

The Director of Value Based Care Regulatory Compliance will lead the markets compliance program for Medicare Advantage and ACO programs, ensuring compliant program design and execution.

• Markets Compliance for Medicare Advantage and ACO Programs
  • Lead the markets compliance program for Medicare Advantage and ACO programs, including ACO LEAD, ACO REACH, and MSSP regulatory and operational requirements.
  • Develop and implement policies, procedures, and training specific to markets compliance program operations.
  • Serve as the primary compliance liaison to physician partner groups, medical directors, and market leadership.
  • Oversee coordination with health plans and downstream partners on compliance program requirements, audit activity, and corrective action.
  • Monitor and communicate CMS risk adjustment policy developments and enforcement trends.
  • Identify compliance gaps across markets and enterprise operations; communicate risks and remediation recommendations.
  • Collaborate with Legal to confirm ACO compliance obligations are met across applicable CMS direct contracting programs.
• Risk Adjustment Oversight for Burden of Illness (BOI) and Clinical Pathways
  • Oversee risk adjustment compliance, including regulatory alignment for the Pre-Member Record Review (PMRR) and BOI program.
  • Ensure risk adjustment program activities are clinically grounded, well-documented, and audit-ready.
  • Provide regulatory compliance support for clinical pathways, partnering with the Clinical team.
  • Collaborate with Clinical, Legal, and Compliance leadership to identify and mitigate regulatory risk.
  • Assess the compliance and regulatory standing of clinical pathway vendors.
• Regulatory Change Management
  • Lead regulatory change management, tracking CMS guidance, OIG updates, and federal and state regulatory developments.
  • Assess regulatory and enforcement developments and translate findings into actionable compliance guidance.
  • Maintain current knowledge of OIG compliance requirements for MCOs, FDRs, health plans, and ACO participants.
  • Develop and present compliance metrics, dashboards, and reports for senior leadership and the internal Compliance Committee.

Qualifications

• Bachelor’s degree in healthcare, business or related field required
• Master’s degree preferred
• CHC preferred; CPC or equivalent risk adjustment coding credential a plus

Requirements

• 7+ years healthcare compliance experience with significant focus on risk adjustment, regulatory affairs, or managed care compliance.
• 5+ years compliance auditing and monitoring experience, including audit program management and team oversight.
• 5+ years supervisory experience managing compliance professionals.
• Substantial experience with CMS program requirements across Medicare Advantage risk adjustment and ACO programs.
• Experience at a health plan, health system, provider group or ACO strongly preferred.
• Background in managed care operation, risk-based contracting or Medicare Advantage compliance preferred.

Skills and Abilities

• Deep knowledge of OIG compliance requirements for MCOs, FDRs, and ACO participants.
• Expertise with risk adjustment coding, RADV audit processes and supplemental data validation.
• Skilled in regulatory change management, including monitoring, analyzing and communicating CMS and OIG guidance.
• Strong capability with preparing and delivering board and senior leadership level compliance metrics and reports.
• Knowledge of value-based care, Medicare Advantage, fraud and abuse laws, and ACO REACH and MSSP programs.
• Demonstrated leadership, sound independent judgment and the ability to operate effectively in a matrixed organization.

Language Skills

• Strong written and verbal communication skills to advise multiple internal clients and external partners.

Reasoning Ability

• Ability to apply legal reasoning and sound judgment to complex, novel regulatory and transactional problems.

Computer Skills

• Ability to create and maintain documents using Microsoft Office (Word, Excel, Outlook, PowerPoint); familiarity with CLM, matter management, or legal operations platforms preferred.

Location

Remote - OH

Pay Range

Salary range shown is a guideline. Individual compensation packages can vary based on factors unique to each candidate, such as skill set, experience, and qualifications.