[Hiring] Program Manager UM Regulatory Compliance @CommonSpirit Health

Role Description

As our Program Manager UM Regulatory Compliance, you are responsible for oversight of delegated audits related to the UM, Credentialing, Claims, Enrollment, and Appeals process, in coordination with DHMSO Compliance, to ensure consistent implementation of contractual obligations between CommonSpirit Health / Dignity Health Compliance and our payers related to the services provided by DHMSO Operations.

• Work closely with various departments to educate staff, update policies and procedures, and workflows to maintain ongoing compliance.
• Act as a liaison between the payers and local market leadership.
• Be involved in payer audits and oversee audit corrective action plans as needed, tracking action plan progress where indicated.
• Work with operational business unit leaders to operationalize and document processes (workflow, desktop level procedures (DLP) impact) as All Plan Letters (APL's), CMS memos, and other communications are received from governing entities.
• Communicate changes with upstream and downstream teams.
• Have exceptional communication skills, the ability to guide others in change, and a strong background in auditing, reviewing, and documenting policies and procedures.
• Work during PST business hours.
• Serve as a subject matter expert on all state and national regulatory bodies for supporting all departments and aligning policies and workflows as needed.
• Oversee regular local auditing to ensure consistent and ongoing compliance with regulations, including the development of action plans to close gaps and improve overall audit results.
• Maintain, in partnership with the Operational leaders, all Operational policies and program descriptions to confirm alignment with regulatory body updates.
• Work with the staff education team on annual regulatory compliance training required by governing bodies and delegated vendors.
• Work proactively with leadership to assist in activities related to audits.
• Assist local leadership and contracting teams with contract delegation.

Qualifications

• Five (5) years experience participating in audits, reviewing, and documenting policies and procedures.
• Bachelor's degree.
• Experience in reviewing and interpreting regulatory requirements.
• Working knowledge of Knox-Keen, DMHC, and CMS rules for Claim Submission, Claim Payment, Eligibility, Appeals for Commercial, MediCare, and MediCal lines of business.
• Guidance and working with others to determine and recommend appropriate process change or process implementation.
• Proven ability to work with other business functions to determine operational impact, recommend best practices, and articulate to leadership.

Requirements

• Ability to create workflow documents (such as using Lucidchart or Microsoft Visio application), create DLPs (Desktop level procedures; i.e., documenting the workflows to be used for training and staff references) experience is a plus.
• Document management/version control experience strongly preferred.
• Experience with Google Workspace and Microsoft Office preferred.

Benefits

• Equipment needed to work from home, including a laptop, docking station, dual monitors, and accessories.

Company Description

One Community. One Mission. One California.