Regulatory Compliance Lead

Description

Under the direction of the Director of Quality and Compliance, the Regulatory Compliance Lead leads and maintains LIFE Pittsburgh’s Compliance Program. The position translates applicable external requirements and internal standards into clear organizational expectations; identifies and prioritizes compliance vulnerabilities; verifies compliance; investigates concerns; and oversees follow-through on corrective action.

Compliance protects participants, employees, public resources, and organizational integrity, supporting LIFE Pittsburgh’s purpose of creating opportunities for people to live safely and with purpose in the home and community they choose. The role promotes lawful, ethical, accountable operations through a consistent compliance structure and credible evidence of performance.

Role relationships and accountability

The Lead provides compliance guidance, independent review, monitoring, and escalation across the organization. Operational leaders remain responsible for compliant service delivery, controls, documentation, and implementation of corrective actions within their areas. The Lead works with those leaders to clarify ownership and verify that corrections achieve the intended result.

The position collaborates with Quality, clinical and operational leadership, Human Resources, Training and Education, Health Information, Technology, Finance, Health Plan Administration, and contractors. Regulatory communications and external submissions are coordinated through the Director and approved organizational channels. Privacy, information security, policy governance, and organization-wide risk work are performed in partnership with the designated owners.

Essential functions

Maintain the Compliance Program structure

• •Maintain the compliance framework, including standards of conduct, policies, reporting channels, oversight processes, and an annual work plan. Coordinate annual review and approval through established leadership and Board processes.
• •Lead Compliance Committee activities, including agendas, documented decisions, issue tracking, follow-up, and reports to the Director and Committee. Support leadership and Board oversight with clear information about material risks, unresolved issues, and program effectiveness.

Identify and translate applicable requirements

• •Track and interpret applicable federal, Pennsylvania, and local requirements, CMS PACE requirements, Medicare and Medicaid obligations, applicable Part D requirements, HIPAA and other privacy and security obligations, applicable workplace safety requirements, program agreements, contractual obligations, and organizational standards.
• •Translate requirements into practical expectations with identified owners, evidence needs, and implementation timelines. Distinguish binding requirements from guidance and internal standards, and seek clarification when interpretation is uncertain.

Assess and prioritize compliance vulnerabilities

• •Maintain a documented assessment of compliance vulnerabilities using regulatory changes, audit findings, incidents, complaints, grievances, contractor concerns, and operating data. Prioritize risks according to potential harm, likelihood, regulatory exposure, and recurrence.
• •Develop a risk-based compliance work plan with defined review activities, responsibilities, and timeframes. Escalate material or emerging risks and contribute compliance information to the organization-wide risk management process.

Monitor and verify compliance

• •Conduct and coordinate internal audits and monitoring to test whether requirements and controls are being followed. Define scope, review criteria, sampling methods, evidence sources, and findings; retain supporting records.
• •Review policies, procedures, records, service-delivery evidence, and relevant data for consistency with requirements. Evaluate contractor compliance in coordination with contract and operational owners.
• •Distinguish internal testing from external regulatory readiness. Identify cross-department patterns, communicate results, and recommend practical improvements based on evidence.

Investigate concerns and verify corrective action

• •Receive, triage, and review suspected or confirmed noncompliance, including hotline reports and potential fraud, waste, abuse, privacy concerns, or operational failures. Coordinate investigations with appropriate internal specialists and leadership.
• •Gather objective facts, determine scope and impact, preserve evidence, and document conclusions. Identify the earliest meaningful breakdown in requirements, ownership, workflow, capacity, training, information, or controls.
• •Coordinate immediate protective action and corrective action plans with the responsible operational owner. Require clear actions, accountable owners, due dates, monitoring tasks, and measures of success.
• •Track implementation, test effectiveness, and verify sustained improvement before recommending closure. Escalate overdue actions, persistent risk, or inadequate results through approved channels.

Promote compliance culture and accountability

• •Maintain accessible reporting mechanisms for employees and contractors, including confidential and anonymous options consistent with organizational processes. Reinforce good-faith reporting and nonretaliation; protect information within appropriate access limits.
• •Partner with Training and Education and subject matter owners to develop compliance education, including standards of conduct, reporting responsibilities, and fraud, waste, and abuse prevention. Monitor completion and evaluate understanding where appropriate.
• •Provide clear, timely guidance and communicate lessons from findings so employees and leaders understand both the requirement and how to meet it in daily work.

Support ongoing regulatory readiness and reporting

• •Coordinate compliance readiness activities for surveys, audits, and external reviews. Maintain organized evidence, track readiness gaps, and work with departments to demonstrate requirements are understood and fulfilled throughout the year.
• •Support accurate, timely regulatory responses and submissions as assigned. Track reporting obligations, deadlines, supporting evidence, and follow-up through approved organizational channels.
• •Coordinate Part D fraud, waste, and abuse reviews with Health Plan Administration and relevant vendors. Support evaluation and authorized reporting of potential fraud to CMS or the appropriate program integrity contractor when required or determined appropriate.

Maintain evidence and evaluate program effectiveness

• •Maintain accurate compliance records, including requirement tracking, assessments, audits, investigations, Committee records, education evidence, regulatory submissions, and corrective action verification, consistent with retention and confidentiality requirements.
• •Report meaningful measures such as work plan completion, unresolved findings, overdue corrective actions, repeat issues, and verified effectiveness. Evaluate whether the Compliance Program detects, prevents, and addresses noncompliance, and recommend improvements.
• •Participate in quality assurance and performance improvement activities as assigned, contributing compliance expertise while preserving operational accountability for the underlying work.

Requirements

Knowledge skills and abilities

• •Ability to research and interpret healthcare requirements and translate them into clear policies, controls, practical guidance, and evidence expectations.
• •Strong auditing, investigation, root cause analysis, data analysis, and process mapping skills; ability to separate facts from assumptions and assess the reliability of evidence.
• •Sound judgment, integrity, discretion, and objective problem solving; ability to maintain confidentiality and handle sensitive concerns fairly.
• •Clear written and verbal communication; ability to educate, facilitate meetings, document findings, and give leadership concise informa