Director of Value Based Care Regulatory Compliance

Company

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AHI agilon health, inc.Job Posting Location: =============================

Remote - USAJob Title: ==================

Director of Value Based Care Regulatory ComplianceJob Description: ========================

Essential Job Functions

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, ensuring compliant program design and execution.
• 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 to drive compliance awareness, education, and accountability.
• Oversee the coordination with health plans and downstream partners on compliance program requirements, audit activity, and corrective action.
• Monitor and communicate CMS risk adjustment policy developments, enforcement trends, and program-specific requirements across Medicare Advantage and ACO programs.
• Identify compliance gaps across markets and enterprise operations; communicate risks and remediation recommendations to the CCO, senior leadership and impacted business areas.
• Collaborate with Legal to confirm ACO compliance obligations are met across applicable CMS direct contracting programs, including ACO REACH, MSSP, and ACO LEAD.

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, coding audit protocols, and OIG high-risk condition monitoring.
• Ensure risk adjustment program activities are clinically grounded, well-documented, and audit-ready in alignment with CMS and OIG expectations.
• Provide regulatory compliance support for clinical pathway