Network Compliance Manager, Principal

Job Description

Your Role

The Network Compliance team works closely with various departments within Blue Shield of California and Blue Shield of California Promise Health Plan, as well as with State regulators to ensure regulatory compliance requirements are met relative to provider networks. The Network Compliance Manager, Principal will report to the Senior Director, Network Compliance. In this role, you will manage all aspects of assigned Commercial and Medi-Cal Block Transfer Filing submissions for regulatory review and approval, including member Transition Plans, and related member notification processes resulting from Hospital and Medical Group contract terminations. You will also support annual Timely Access Compliance Reporting to the California Department of Managed Health Care and the Annual Network Review submission to the California Department of Insurance.

Responsibilities

Your Work

In this role, you will:

• Develop and sustain positive relationships with state regulators, i.e. DMHC, CDI, DHCS, and plan partner LA Care Health Plan, while acting as the project contact with authority to exercise judgement in resolving concerns for the company
• Operationalize the enactment of new and revised State mandates affecting Commercial, Medi-Cal, and Medicare Advantage networks
• Manage Commercial and Medi-Cal Block Transfer Filings, Transition Plan Filings for Medi-Cal, and Timely Access Compliance Report filings for State review, such as Transition Planning due to network contract terminations, and facilitation of related member notification processes
• Assist other departments with compliance-related tasks, such as enrollee reassignments, Annual Network Review filings, Material Modification Filings, RFPs, and other State filings
• Manage compliance reporting for commercial and state-sponsored business, e.g. Timely Access Reporting (TAR) and related analytics, as well as present results to internal departments, committees, and external organizations
• Facilitate weekly transition and disengagement meetings with multiple departments to ensure operational readiness
• Write and update policies and procedures that support State mandates affecting networks and submit policies for review and approval to regulators
• Respond to regulators' comments and/or objections concerning filings
• Direct vendor activities for assigned regulated surveys and participate in vendor procurement activities, e.g., initial Statement of Work development and renewal
• Oversee regulatory compliance activities for large, complex project initiatives of strategic importance to the organization, involving cross-functional teams

Qualifications

Your Knowledge and Experience

• Requires a college degree or equivalent experience
• Requires 10 years of prior relevant experience
• Requires ability to communicate with executive leadership regarding matters of significant importance to the organization
• Requires strong technical writing skills
• Requires mastery level knowledge of job area typically obtained through advanced education combined with experience, including knowledge of project management
• Ability to communicate and influence internal and external parties including state regulators, vendors, Plan Partners, and clinicians
• Certified in Healthcare Compliance (CHC) designation is preferred

About the Team

Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

At Blue Shield of California, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:
  
  • Member-facing and approved out-of-state roles remain remote.
  • Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
  • For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.