Provider Network Program Manager – Cost Calculator

Job Category: Network Management

Requisition Number: PNPRO
006079

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This role is responsible for end-to-end program management, operational execution, and compliance support for Medica’s Cost Calculator tool and associated data. The position ensures accurate, compliant, and timely delivery of cost transparency capabilities, including implementation of regulatory requirements, ongoing product enhancements, and coordination across internal and external partners. The role serves as the primary operational lead for sustaining and advancing the tool while supporting enterprise transparency and member experience objectives.

Performs other duties as assigned.

• Lead Cost Calculator Operations & Program Execution
  • Manage implementation of new and updated products, services, and integrations (e.g. WebTPA migration, APR-DRG additions, enhancements to tool functionality) and decommissioning of retired products
  • Coordinate user acceptance testing (UAT) and validate successful system and data changes
  • Oversee transition initiatives (e.g., single search experience) and ensure delivery against timelines
  • Partner with IT, vendors (e.g., Kyruus Health), and internal stakeholders to execute roadmap items
• Ensure Ongoing Compliance & Regulatory Alignment
  • Support compliance with Transparency in Coverage (TiC) and CMS requirements, including large-scale regulatory updates
  • Ensure adherence to Public Facing Machine Readable Files requirements of the Transparency in Coverage Mandate, working with Medica IT and Compliance Teams
  • Maintain required disclosures (preventive, prior authorization, step therapy, etc.) and ensure accuracy and legal appropriateness of published information
  • Monitor regulatory changes and translate requirements into operational and system updates
  • Partner with compliance and legal teams to mitigate risk and support audits or inquiries
• Perform Ongoing Maintenance & Data Integrity Oversight
  • Monitor and maintain provider and cost data feeds to ensure accuracy and completeness, including alignment of provider data to Cost Calculator requirements and changes resulting from source system replacements
  • Manage updates to negotiated rates, provider information, and code sets (e.g., CMS code updates)
  • Identify and drive resolution of data discrepancies and support root‑cause analysis
  • Maintain relationships with delegated entities and partners (e.g., Optum, UHC, leased networks) to ensure data quality
• Drive Program Coordination, Reporting & Stakeholder Engagement
  • Lead recurring operational meetings, status reporting, and cross-functional coordination (IT, digital, compliance, operations)
  • Compile usage metrics and provide insights to support decision‑making and roadmap prioritization
  • Develop and obtain required approvals for business cases, risk assessments, and business decision documents as needed
  • Serve as a key point of contact for vendor and internal leadership communications including vendor’s regular product reviews and round tables
  • Manage the library of previous documentation of the initiative
• Support Issue Resolution & Continuous Improvement
  • Triage and drive resolution of member and operational issues related to the Cost Calculator experience
  • Support customer service teams with current and future tool‑related inquiries and workflows (live over the phone estimates)
  • Identify process improvements and automation opportunities to increase efficiency and reduce errors
  • Contribute to training, documentation, and change management efforts

• Bachelor's degree or equivalent experience in related field
• 7+ years of related work experience beyond degree

Strong project and program management skills with the ability to lead complex, cross‑functional initiatives from planning through implementation.

Working knowledge of CMS regulations, healthcare compliance requirements, and other regulatory standards impacting provider network and cost transparency initiatives.

Ability to assess downstream impacts of strategic, operational, and technical decisions across members, providers, business teams, and systems.

Strong critical thinking and problem‑solving skills with the…