Providence Network Regulatory and Compliance Program Manager in Portland, Oregon
Providence St. Joseph Health is calling a Network Regulatory and Compliance Program Manager to our location in Portland, OR, or WA.
We are seeking a Network Regulatory and Compliance Program Manager who will be responsible for working in highly complex and dynamic legal and regulatory environment. Multiple health plan products and functioning within two separate jurisdictions adds additional complexity. Must be able to understand and track the changing regulatory and accreditation requirements as it pertains to provider contracting and network requirements. Work in conjunction with Legal, RCGA and department leadership to ensure contract documents are compliant and contracts are filed appropriately without impeding the business and strategic objectives of the organization. Must have ability to lead and facilitate cross-functional deliverables such as Form A Network Reporting to ensure compliance, holding other departments and external vendors accountable to meet their deliverables.
State contract and network requirements are complex, often changing and required to continue to do business in that state. WA OIC in particular has significant, complex and often changing provider contracting, provider contract filing, reporting and network regulatory requirements. Failure to comply will risk PHP's ability to do business in WA. These requirements have significant impact on network design and configuration, provider contracting, provider contract negotiations. There are regularly new language requirements, changes in the WA OIC analyst interpretation of the regulations or different guidance potentially requiring complete re-contracting or a complete change in the contract structure. There are strict filing requirements. The Provider Reporting is complex, occurs monthly, requires quick turnaround for errors, and requires close cooperation with other departments.
In this position you will have the following responsibilities:
Understand and stay current with state regulatory and accreditation requirements pertaining to provider networks and contracts. Accountable to research and understand all current and potential future WA OIC and Oregon regulations as it pertains to provider contracting, network design and network reporting.
Familiar with provider contracts and contracting process to understand impact of new requirements. Draft contract language and/or policies or procedures as needed, to ensure compliance with WA, OR and NCQA requirements. Responsible for ensuring that contract compliance documents are up to date.
Accountable for preparing all WA provider contract and contract template filings including checklist. Must submit all complete and timely contract filings for WA provider contracts to RCGA (Regulatory Compliance Govt Admin) ; Track status of filings. Maintain contract filing tracking log that includes date submitted, date filed and status.
Accountable to work with network delegates to ensure they are in compliance with all WA OIC requirements for Providence Health Plan and all downstream contracts.
Point of contact for RCGA for WA OIC provider contract filings, and responsible to collaborate with RCGA to understand and develop responses for contract objections.
Responsible with Director of Provider Contracting, to facilitate and hold all departments accountable for Form A monthly reporting on a timely basis. Lead/participate in Form A Steering/SWAT Team. Work with network delegates to ensure provider information is incorporated into Form A. Manage monthly error report and process for timely resolution. Develop and maintain contract crosswalk for Form A.
Accountable to meet Regulatory Contract Compliance as well as NCQA Accreditation requirements across all lines of business including Medicare, Medicaid, Commercial, PPO and MSO. This includes ensuring all contracts are provided in the required format to RCGA for filing and that all required language is incorporated in required structure as well as overseeing HSD table accurate creation and monitoring.
Point of contact for audits.
Serves as a departmental resource for training and as an organizational resource and department representative for regulatory and compliance matters.
Communicates to Contracting and Provider Relations new regulatory requirements including reporting, and network adequacy requirements for WA and OR.
Required qualifications for this position include:
Bachelor's Degree in Business, healthcare, or closely related field.
5 years relevant experience working in or with a health plan or healthcare organization.
Track record for developing effective business relationships and working cooperatively with others.
Familiar with healthcare regulatory entities such as CMS, OR and WA insurance divisions
Experience with drafting contract language, and other business documents.
Preferred qualifications for this position include:
Master's Degree or equivalent education/experience.
Project manager and/or program manager experience, including program planning, development and evaluation.
About Providence in Oregon.
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple, "Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Project & Program Management (Non-Clinical)
Req ID: 289214