Provider and Network Compliance Manager

Health Partners is hiring a Provider and Network Compliance Manager
. The Provider and Network Compliance Manager serves as an organizer, facilitator, planner, and problem solver for compliance-related projects across Provider Electronic Commerce and Operations and the Contracted Care Division. This role oversees government and regulatory compliance for health plan providers and networks, ensuring adherence to contracts and policies and procedures. The position also supports strategic initiatives, network adequacy filings, and HIPAA compliance projects, acting as a liaison between internal departments and external regulatory bodies.

• Education, Experience or Equivalent Combination
• Bachelor s degree in Business or Health Care Administration, or another related field
• 5 years of experience in managed health care/insurance industry
• Knowledge, Skills, and Abilities:
• 3 years of Project management
• Experience utilizing Excel and Power BI reports and dashboards to analyze data
• Solid understanding of accreditation and regulatory requirements related to Medicare, Medicaid and individual market health insurance exchanges

• Education, Experience or Equivalent Combination:
• Master s degree in Business or Health Care administration
• Licensure/ Registration/ Certification:
• Health Care Compliance certificate
• Knowledge, Skills, and Abilities:
• Experience with health provider contracting processes
• Supervisory or personnel management experience
• Understanding of Agile development or continuous improvement methodologies

The Provider Compliance Manager operates with broad latitude and independence in directing resources and executing strategies to achieve compliance and operational objectives. This position is responsible for:

• Regulatory tracking, analysis, implementation and ongoing guidance
• Leading regulatory update communications to the health plan contracted providers
• Ensuring cross-functional alignment, providing visibility and escalating key decision-making/risk assessment to senior leadership and the legal department
• Utilizes reporting to manage data accuracy, monitor compliance rates and network configuration

This management position supervises a team that includes analysts, specialists and data analysts to ensure provider data and network compliance needs are met.

This position works collaboratively within the Provider Electronic Commerce & Operations department. This manager acts as a resource for the department to clarify regulatory needs and coordinates the compliance team in the development of operational, system or reporting changes needed to support compliance efforts.

Additionally, this manager interacts routinely with the following departments:

• Government Programs:
  Collaborates to implement DHS contract updates and reviews bulletins and final rules related to Medicare.
• Integrity & Compliance:
  Partners to complete regulatory audits to ensure adherence to all relevant compliance standards.
• Provider Relations & Network Management:
  Coordinates to verify providers have completed necessary regulatory documentation and provides guidance on network adequacy requirements.
• Product/Market Innovations:
  Works jointly on annual filings to support new and ongoing product offerings.
• Sales:
  Coordinates with account managers for custom networks and RFP submissions

• Marketing:
  Collaborates on the creation of printed provider directories for members.
• Web & Mobile:
  Engages with the team to maintain and update online provider directories.
• Government Relations:
  Reviews proposed or new legislation to determine impacts to operations