Regulatory Operations Senior Manager

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Regulatory Operations Senior Manager within the COO division is responsible for ensuring division-wide compliance with federal and state regulatory requirements. This role drives the implementation of complex regulatory guidance, oversees high-stakes audit activities, and partners with executive and departmental leadership to develop and embed robust internal controls. This position plays a critical role in aligning regulatory operations with business strategy, proactively managing risk and representing the organization in regulatory and audit interactions.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Responsibilities:

• Provide strategic oversight for the review and implementation of federal (CMS, HPMS) and state (DHHS) regulatory guidance, including proposed and final rules, benefit manual changes, and contract amendments.
• Lead the COO division's end-to-end audit preparedness and response strategy for all state, federal, and internal audits across Medicaid and Medicare lines of business.
• Serve as the division's primary point of contact for regulatory audits and manage cross-functional teams in developing corrective action plans and post-audit remediations.
• Direct the development, standardization, and governance of documentation and internal controls to ensure compliance with regulatory, contractual, and accreditation standards.
• Act as a strategic advisor to operational and business leaders in interpreting regulations and operationalizing compliance through scalable processes, workflows, and systems.
• Oversee divisional efforts to maintain regulatory accuracy and completeness in member-facing communications, internal policies, and procedural documentation.
• Partner with Training and Compliance teams to build and deliver comprehensive staff training programs on regulatory changes and audit-readiness.
• Establish and maintain centralized systems and repositories for regulatory correspondence, filings, and RFP responses to ensure transparency and continuity.
• Collaborate closely with leadership, Compliance, Legal, Public Partnerships, and other stakeholders to align compliance objectives with organizational priorities.
• Provide leadership on enterprise committees and workgroups dedicated to program compliance, quality assurance, and regulatory strategy.
• Monitor and manage the audit calendar and ensure preparedness for routine and ad hoc audits, including but not limited to:




• NH EQRO and PMV audits (annual)
• MA SCO and ACO/MCO EQRO audits (triannual)
• CMS data validation and ad hoc program audits
• State Medicaid operational, financial, and network audits
• CMS call center compliance reviews

Competencies, Skills, and Attributes:

* Exceptional organizational acumen with a track record of designing and implementing scalable, process improvements that drive operational efficiency and regulatory compliance.

* Advanced regulatory interpretation capabilities, with the ability to analyze, extract, and operationalize complex requirements from state and federal contracts, guidance, and legislation.

* Excellent communication skills, both written and verbal, with the ability to effectively influence, present to, and collaborate with stakeholders across all organizational levels, including senior leadership and external regulators.

* Proficient in Microsoft Office 365 suite (Excel, Word, PowerPoint, Outlook, Teams, SharePoint), with demonstrated ability to leverage these tools to support project management, reporting, and collaboration.

* Proven leadership in program and project management, with the ability to prioritize competing initiatives, allocate resources effectively, and deliver results on time and within scope in a fast-paced regulatory environment.

* High attention to detail and strong editorial skills, ensuring the accuracy and clarity of compliance documentation, policies, reports, and member-facing communications.

* Skilled facilitator of cross-functional collaboration, adept at building consensus, driving alignment, and fostering productive communication across diverse business units and matrixed teams.

* Self-directed and results-oriented, with demonstrated ability to independently lead initiatives, manage ambiguity, and execute on multiple priorities simultaneously with minimal supervision.

* Customer-centric mindset, with a strong commitment to delivering responsive, high-quality service to both internal stakeholders and external partners, including regulators.

* Experience navigating complex matrixed organizations, effectively managing cross-departmental dependencies, and influencing without direct authority.

* Change agent with a continuous improvement mindset, capable of identifying inefficiencies and leading initiatives that enhance regulatory operations and audit readiness.

* Strong interpersonal and stakeholder engagement skills, with the ability to build trust and credibility across diverse audiences, including executive leadership, auditors, and regulatory agencies.

* Analytical and strategic problem solver, leveraging data and critical thinking to assess risks, identify root causes, and develop innovative, compliant solutions.

Supervision and Leadership:

• This is a senior individual contributor role with significant cross-functional influence and strategic leadership responsibilities.
• May provide mentorship and informal leadership to team members and project teams.
• Reports to the Senior Vice President of Service & Operations and works in close coordination with Corporate Compliance and Regulatory Reporting functions.

Supervision Exercised:

* This is an individual contributor role

Supervision Received:

* General guidance is received weekly

* This role will report to the SVP of Service & Operations and will work with Senior leaders across the division and the corporate compliance department

* This role will work closely with the COO division regulatory reporting analyst, public affairs department and business leaders

* This role will interact with internal or external auditors or state and federal agencies

Qualifications:

Education Required:

• Bachelor's Degree or an equivalent combination of education, training and experience is required

Education Preferred:

* Master's degree in a related field preferred

Experience Required:

• 10+ years of managed care experience in compliance or government programs

* 10+ years of experience with Medicare or Medicaid programs

* 5+ years of experience with regulatory contracts and requirements

Experience Preferred/Desirable:

• Health plan operations experience

Required Licensure, Certification or Conditions of Employment:

* Successful completion of pre-employment background check

* Employees must provide high speed internet meeting minimum required standards

* Employees are required to have a quiet and distraction-free working space and protect confidential information

Working Conditions and Physical Effort:

• Ability to work in a fast-paced environment
• Regular and reliable attendance is an essential function of the position
• Work is normally performed in a remote office work environment; limited travel may be required
• Ability to work East Coast business hours
• No or very limited physical effort required
• No or very limited exposure to physical risk

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees