Job description

Your Role The Network Compliance team collaborates to ensure regulatory compliance with regulations pertaining to HMO, PPO, Medicare, and Medi-Cal provider network disruptions. The Network Compliance Manager, Principal, will report to the Sr. Manager of Network Operations. In this role you will serve as the primary liaison with state regulators and plan partners, ensuring strong regulatory relationships while overseeing compliance with evolving state requirements across Commercial, Medicare Advantage, and Medi-Cal lines of business. You will help lead critical regulatory initiatives, including block transfers, provider termination transition planning, member notification processes, and required state filings, while exercising judgment to resolve complex compliance issues. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning. Your Work In this role, you will: • Develop and sustain positive relationships with state regulators, i.e. DMHC and CDI; DHCS; and plan partner LA Care, while acting as project contact with authority to exercise judgement in resolving concerns for the company • Operationalize the enactment of new and existing State requirements affecting Commercial, Medicare Advantage, and State-Sponsored Business • Manages all aspects of commercial and state-sponsored Block Transfer and Timely Access Report filings for State review, such as Transition Planning due to network provider terminations, and facilitation of related member notification processes • Assists other departments with compliance-related tasks, such as enrollee reassignments, Timely Access Reporting filings, Material Modification Filings, and other State filings • Manage compliance reporting, for commercial and state-sponsored business, e.g. Timely Access Reporting (TAR) and related analytical analysis; as well as presenting results to internal departments, committees, and external organizations • Develop and update policies and procedures relative to State filing requirements. Submits policies for review and responds to comments or objections. • Ensures compliance with State/Federal orders and finds solutions to ensure compliance that optimizes company operations relative to imposed conditions or undertakings • Provides guidance, direction, training and assistance as needed on matters related to regulators • Responsible for proactively improving upon existing processes and systems using significant conceptualizing, reasoning and interpretation. Results may serve as precedent for future decisions Your Knowledge and Experience • Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree • 10 years of prior relevant experience • 5+ years of progressive experience in health plan compliance, required • DMHC experience and block transfer experience strongly preferred • Strong interpersonal and verbal and written communication skills • Works independently under limited supervision • Detail oriented and has the ability to deal with complexity, compressed timelines and shifting priorities • Advanced proficiency with MS Office products is required, including Word, PowerPoint and Excel. • CHC designation or another related credential preferred Hybrid This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week. Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need. The Network Compliance Manager, Principal, will report to the Sr. Manager of Network Operations. In this role you will serve as the primary liaison with state regulators and plan partners, ensuring strong regulatory relationships while overseeing compliance with evolving state requirements across Commercial, Medicare Advantage, and Medi-Cal lines of business. You will help lead critical regulatory initiatives, including block transfers, provider termination transition planning, member notification processes, and required state filings, while exercising judgment to resolve complex compliance issues.

Requirements

Must-haves

Operationalize the enactment of new and existing State requirements affecting Commercial, Medicare Advantage, and State-Sponsored Business
Assists other departments with compliance-related tasks, such as enrollee reassignments, Timely Access Reporting filings, Material Modification Filings, and other State filings
Develop and update policies and procedures relative to State filing requirements. Submits policies for review and responds to comments or objections.
Ensures compliance with State/Federal orders and finds solutions to ensure compliance that optimizes company operations relative to imposed conditions or undertakings
Provides guidance, direction, training and assistance as needed on matters related to regulators
Responsible for proactively improving upon existing processes and systems using significant conceptualizing, reasoning and interpretation. Results may serve as precedent for future decisions
Your Knowledge and Experience
Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
10 years of prior relevant experience
5+ years of progressive experience in health plan compliance, required
Strong interpersonal and verbal and written communication skills
Works independently under limited supervision
Detail oriented and has the ability to deal with complexity, compressed timelines and shifting priorities
Advanced proficiency with MS Office products is required, including Word, PowerPoint and Excel.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

Nice-to-haves

DMHC experience and block transfer experience strongly preferred
CHC designation or another related credential preferred

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Platform: oracle-cloud
Effort: medium

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