Network Compliance Manager, Principal

Your Role

The Network Compliance team works closely with various departments within Blue Shield of California and Blue Shield of California Promise Health Plan, as well as with State regulators to ensure regulatory compliance requirements are met relative to provider networks. The Network Compliance Manager, Principal will report to the Senior Director, Network Compliance. In this role, you will manage all aspects of assigned Commercial and Medi-Cal Block Transfer Filing submissions for regulatory review and approval, including member Transition Plans, and related member notification processes resulting from Hospital and Medical Group contract terminations. You will also support annual Timely Access Compliance Reporting to the California Department of Managed Health Care and the Annual Network Review submission to the California Department of Insurance.

Your Work

In this role, you will:

• Develop and sustain positive relationships with state regulators, i.e. DMHC, CDI, DHCS, and plan partner LA Care Health Plan, while acting as the project contact with authority to exercise judgement in resolving concerns for the company 
• Operationalize the enactment of new and revised State mandates affecting Commercial, Medi-Cal, and Medicare Advantage networks
• Manage Commercial and Medi-Cal Block Transfer Filings, Transition Plan Filings for Medi-Cal, and Timely Access Compliance Report filings for State review, such as Transition Planning due to network contract terminations, and facilitation of related member notification processes  
• Assist other departments with compliance-related tasks, such as enrollee reassignments, Annual Network Review filings, Material Modification Filings, RFPs, and other State filings 
• Manage compliance reporting for commercial and state-sponsored business, e.g. Timely Access Reporting (TAR) and related analytics, as well as present results to internal departments, committees, and external organizations 
• Facilitate weekly transition and disengagement meetings with multiple departments to ensure operational readiness
• Write and update policies and procedures that support State mandates affecting networks and submit policies for review and approval to regulators
• Respond to regulators’ comments and/or objections concerning filings
• Direct vendor activities for assigned regulated surveys and participate in vendor procurement activities, e.g., initial Statement of Work development and renewal
• Oversee regulatory compliance activities for large, complex project initiatives of strategic importance to the organization, involving cross-functional teams

Your Knowledge and Experience

• Requires a college degree or equivalent experience
• Requires 10 years of prior relevant experience
• Requires ability to communicate with executive leadership regarding matters of significant importance to the organization
• Requires strong technical writing skills
• Requires mastery level knowledge of job area typically obtained through advanced education combined with experience, including knowledge of project management
• Ability to communicate and influence internal and external parties including state regulators, vendors, Plan Partners, and clinicians
• Certified in Healthcare Compliance (CHC) designation is preferred