CareFirst Careers

Dir, QI, Comp, & Reg Oversight

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Resp & Qualifications

This position reports directly to the Senior Director of Operations Technical Support, Compliance and Quality and is accountable for managing all aspects related to the overall state of Compliance for the Networks Management Division (NM).

This position is directly accountable for ensuring the integrity of the Compliance and Audit process for NM.  This position has the responsibility for evaluating and maintaining compliance and audit protocols for the NM division in coordination with Corporate Compliance, Corporate Audit & Assurance Services (CAAS), Sarbanes Oxley, MTM and Legal. Works with the Senior Director of OTS, Compliance and Quality to manage the activities related to the design, development, reporting and oversight of compliance program to ensure that each functional area within NM remains in compliance and alignment with Federal and State regulatory requirements and mandates, as well as corporate and divisional goals and requirements.  

Works to ensure that each functional team within NM incorporate criteria needed to monitor regulatory compliance in each functional area. Maintains documentation and reporting of evidence of compliance / policies and procedures. Regularly monitors and controls correction action plan implementation and communicates risks associated with the control deficiencies identified to all stakeholders.

PRINCIPAL ACCOUNTABILITIES: Under direction of the Senior Director of Operations Technical Support, Compliance and Quality, the incumbent’s accountabilities include, but are not limited to the following:

Compliance Program Management

  • Oversees the implementation and management of the division’s Compliance program to ensure compliance and alignment with Federal, State regulatory statutes.
  • Develops and manages a compliance program to effectively implement, revise and test controls and continuously reviews and improves departmental policies and procedures to achieve greater efficiencies and effectiveness.
  • Provide interpretation of regulations and regulatory rules/guidelines to demonstrate NM and its delegated entities are in compliance with state and federal standards.  With regard to compliance-related policies, the Director will gather and organize applicable insurance laws and regulations (mandates) into a central content repository and ensure that a department policy, procedure and audit criteria to measure compliance exists for each law/regulation. 
  • Continuously analyzes and aligns all functional area policies, procedures, SOPs, workflows, and systems and ensure they are in compliance and alignment with regulations and remain updated and current. 
  • Reviews complex business processes, systems, workflows, SOPs and policies, procedures to identify, document, and elevate the presence of risks and trends within, that may be non-compliant with contracts and or statutory requirements.
  • Works directly with the division’s Training teams to ensure training content incorporates necessary procedures, SOPs, workflows, etc. applicable to the policies.
  • Reviews and makes recommendations for workforce management related to productivity and overtime. 
  • Reviews internal controls, both manual and automated, and/or management controls in each functional area to remove any risk or exposure. 
  • Analyzes controls for strengths and weaknesses and ensures that special focus is allocated to the specific risk areas creating the highest exposure to the division.  
  • Support Audits and manages the activities related to reviewing audit findings with stakeholders.
  • Works with division’s management to establish and implement corrective action plan as an outcome of any audit findings.

Monitoring and Reporting

  • Regular monitoring and control of corrective action plan implementation and communication/reporting of risk associated with the control deficiencies identified to all stakeholders.
  • Actively coordinate and participate in implementation/corrective workgroups to ensure compliance perspective and concerns are addressed through the process.
  • Acts as a liaison across all areas internally including all of NM, Corporate Audit, Corporate Compliance, Finance, Medical Affairs and Legal.
  • Provide regular investigative, analytic and audit reporting data to all stakeholders.
  • Ensure documentation is developed and maintained to support progress of projects. Drives the development of workflow process to manage the impact of various projects on multi-departmental workforces and their daily activities.
  • Monitors, assesses, and reports significant matters to senior management.
  • Keeps abreast of emerging issues and developments that have direct impact on the division.
  • Oversees daily, weekly, and quarterly progress updates of all projects and data when necessary.

Direct, coach and lead staff.  Responsible for all duties associated with position; direction and vision for policy and quality standards for all departmental work; associate action plans and performance evaluations; tactical planning, implementation, monitoring and reporting; budget and expense planning; ad hoc executive management reporting.

Compliance for EEO/AAP and all other CareFirst compliance responsibilities.  Ensure that all Associates complete the online compliance training and certifications. Submit all departmental regulatory filing and reports by the associated statutory deadlines.  Operate department within the expected Federal and State legal and regulatory requirements.



This position will have direct supervisory responsibility over a newly established team of Compliance Analysts but may also serve as a task leader for projects.


Required:  Master’s degree or a minimum of 7-10 years experience in the health care industry and a minimum of 5 years management experience

  • Generally conversant with the laws, regulations and guidelines affecting CareFirst
  • Demonstrated ability to plan, direct and manage divisional activities to ensure the achievement of corporate and divisional goals
  • Experience in complex/analytical regulatory compliance
  • Experience in Compliance monitoring, Audits, project management, business process analysis, work flow, and task analysis
  • Flexibility and the ability to work under time constraints, adapt to shifting priorities, to work independently as well as part of a team are required.


  • Ability to present and discuss regulatory compliance goals in a way that establishes rapport, persuades others, and gains commitment
  • Ability to research complex issues, interpret regulations and regulatory rules/guidance, and exhibit sound judgment in determining a recommendation or solution to a problem.
  • Ability to interact effectively with people at different organizational levels, both internally and externally and build and maintain relationships within the company and in the community 
  • Strong interpersonal skills: ability to work and make decisions independently and in a team environment
  • Incumbent must display leadership qualities, functional expertise, and business perspective
  • Ability to gather and analyze data and generate reports
  • Strong problem solving abilities
  • Excellent planning, organizational skills
  • Proficient in computer software applications
  • Self-directed with ability to work independently and make decisions in a changing environment
  • Excellent oral and written communications; able to communicate and make presentation to all levels of management and associates at all levels throughout the Company
  • Understanding of legal requirements and expectations for health insurance operations


Department: Compliance and Audit

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 7/22/2018

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any disbarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully.  Requirements may be modified to accommodate individuals with disabilities.

The employee is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The employee must frequently talk and hear.  Weights of up to 25 pounds are occasionally lifted. Travel to other CareFirst sites may be required.

Must be able to independently drive your own car or take public transporation to and from provider offices, CareFirst offices and/or other business meetings in the Baltimore/Washington metropolitan area.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

Learn more about Medical Management