Senior Director of Licensing & Compliance - PBM

Position Summary

The Senior Director of Licensing & Compliance will lead licensing operations and regulatory compliance initiatives across multiple domestic entities, specifically in Pharmacy Benefit Management (PBM), Third-Party Administrator (TPA), and Stop-Loss operations. This role is responsible for ensuring compliance with federal and state regulations, streamlining licensing processes, and strengthening compliance frameworks. This position serves as the principal corporate resource for regulatory interpretation and application to support strategic business initiatives.

DUTIES AND RESPONSIBILITIES

The essential functions include, but are not limited to the following:

Regulatory Compliance Oversight

• Monitor and interpret federal and state regulations including DOL, CMS, ERISA, ACA, HIPAA, and DOI requirements.
• Develop, implement, and refine compliance policies and procedures.
• Maintain regulatory calendars and compliance dashboards.
• Advise senior leadership on regulatory changes and their business impacts.

Licensing Management

• Oversee licensing applications, renewals, and regulatory reporting for PBM, TPA, and Stop-Loss.
• Evaluate and optimize licensing processes through technology solutions.
• Assist employees with individual licensing renewals.
• Serve as liaison with regulatory agencies, managing inquiries and audits.

Compliance Program Development

• Design comprehensive compliance programs aligned with corporate goals.
• Conduct risk assessments and internal audits.
• Develop and lead compliance training programs.
• Oversee external audits and third-party assessments.
• Establish protocols for internal investigations and remediation.

Cross-Functional Collaboration

• Advise on regulatory matters during mergers, acquisitions, or expansions.
• Act as compliance expert during contract negotiations.
• Collaborate with Legal, Clinical Strategy, Pharmacy Network, and Customer Service teams.
• Respond to regulatory complaints and inquiries.

Reporting and Documentation

• Prepare compliance reports for senior leadership and regulatory agencies.
• Maintain detailed compliance records, including audits and investigations.
• Oversee responses to regulatory engagements and exams.
• Complete government census surveys and regulatory filings.

Other job duties include, but are not limited to the following:

• Supervising compliance and licensing team members.
• Ensuring timely and accurate reporting to regulatory bodies.

MINIMUM QUALIFICATIONS (KNOWLEDGE, SKILLS, AND ABILITIES)

Education

• Bachelor’s degree in Business Administration, Healthcare Administration, Law, or related field (required).
• Master’s degree (MBA, MHA, JD) strongly preferred.

Experience

• 10 years in healthcare regulatory compliance, with expertise in PBM, TPA, or Stop-Loss operations. Required.
• Proven experience developing and managing compliance programs.
• Expertise in federal and state healthcare regulations.
• Team and vendor management experience.

Skills & Competencies

• Proficiency with compliance management systems and automation platforms.
• Strong analytical, leadership, and problem-solving skills.
• Excellent communication and collaboration abilities.
• Detail-oriented and committed to accuracy and integrity.
• Ability to manage and develop compliance teams.

Certifications

• Certification in Healthcare Compliance (CHC) or equivalent (preferred).
• Commitment to continuing education in compliance and healthcare law.

OTHER DETAILS

Supervisory Responsibilities

Manages compliance and licensing teams, providing coaching, performance management, and professional development.

Work Environment

The noise level in the work environment is usually low to moderate.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is occasionally required to stand; walk; sit; and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus.

Travel Requirements

Up to 20% travel may be required.