[Remote] Program Manager UM Regulatory Compliance

Note: The job is a remote job and is open to candidates in USA. CommonSpirit Health is hiring a Program Manager UM Regulatory Compliance to oversee delegated audits and ensure compliance across utilization management and related operational processes. The role coordinates with internal departments, payers, and local leadership to implement regulatory updates, maintain policies and workflows, and track corrective action plans.

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
• 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

Skills

• Five (5) years experience participating in audits, reviewing and documenting policies and procedures
• Bachelors degree or equivalent experience
• 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
• 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

Benefits

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

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