Program Manager UM Regulatory Compliance

Dignity Health Management Services; United States; Remote; USD 85,000 - 110,000; Full time

Job summary

Dignity Health Management Services is seeking a Program Manager UM Regulatory Compliance to oversee delegated audits across UM, Credentialing, Claims, Enrollment, and Appeals. You will coordinate with Compliance to ensure contractual obligations with payers are met, educate staff, and streamline policies and workflows.

As a remote employee, you will partner with multiple departments, manage payer audits, and drive action plans to close gaps while aligning with regulatory updates and vendor

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-Keene, DMHC and CMS rules for Claim Submission, Claim Payment, Eligibility, Appeals for Commercial, Medicare and Medicaid 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 practice and articulate to leadership.

Responsibilities

• Oversee delegated audits related to UM, Credentialing, Claims, Enrollment, and Appeals.
• Educate staff, update policies and workflows to maintain compliance.
• Act as liaison between payers and market leadership; manage payer audits and corrective action plans.
• Operationalize regulatory communications (APL/CMS memos) with upstream and downstream teams.
• Develop and communicate process changes; guide staff in change management.

Skills

Auditing

Policy documentation

Regulatory compliance

CMS rules understanding

Cross-functional collaboration

Education

Bachelor's degree

Tools

Lucidchart

Microsoft Visio

Google Workspace

Job description

Where You'll Work

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

One Community. One Mission. One California

Job Summary and Responsibilities

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.

Every day you will work closely with various departments to educate staff, update policies and procedures and workflows to maintain ongoing compliance. You will also 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. As All Plan Letters (APL's), CMS memos and other communications are received from governing entities, you will be responsible for working with the operational business unit leaders to operationalize and document the process (workflow, desktop level procedures (DLP) impact), and communicate changes with upstream and downstream teams.

To be successful in this role, you will have exceptional communication skills, the ability to guide others in change, and a strong background in auditing, reviewing and documenting policies and procedures.

As a remote employee, we will provide you with the equipment needed to work from home, including a laptop, docking station, dual monitors, and accessories.

This position will be expected to work PST business hours.

• Subject matter expert on all state and national regulatory bodies for supporting all departments and align policies and workflows as needed.
• Oversee regular local auditing to ensure consistent and ongoing compliance to regulations including 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.

Job Requirements

Required

• Five (5) years experience participating in audits, reviewing and documenting policies and procedures
• Bachelors 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 practice and articulate to leadership

Preferred

• Ability to create workflow documents (such as using Lucidcart 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