Clinical Regulatory Oversight, Program Manager V

Medica•St. Louis, MO

5h•$100,300 - $172,000•Hybrid

About The Position

The Clinical Regulatory Oversight Program Manager is responsible for supporting the operational implementation, execution, and ongoing oversight of federal, state, and accreditation requirements impacting Clinical Services, including Utilization Management (UM), and Appeals and Grievances (AG) and Care Management (CM). This role serves as a clinical regulatory subject matter expert, ensuring policies, procedures, workflows, letter templates, and delegated vendor activities remain compliant with applicable regulatory standards. The Program Manager partners closely with the Manager, Clinical Regulatory Oversight; Business Analysts; and cross-functional stakeholders to support regulatory implementations, audits, NCQA deliverables, and continuous compliance improvement efforts. Performs other duties as assigned.

Requirements

Bachelor's degree or equivalent experience in related field, preferred degree in Nursing.
8+ years of experience in clinical, regulatory, Utilization Management, or compliance related roles beyond degree.

Nice To Haves

Valid Registered Nurse (RN) license preferred.
Experience interpreting federal and state healthcare regulations.

Responsibilities

Support implementation and operationalization of new and updated federal and state regulatory requirements affecting clinical services.
Interpret clinical regulatory guidance and translate requirements into workflows, policies, and procedures.
Provide clinical regulatory consultation to internal partners.
Support revisions to UM, AG, and CM letters and templates.
Draft and maintain clinical policies, procedures, and job aids.
Ensure document version control and archival standards are followed.
Support development and validation of NCQA deliverables and audit materials.
Participate in readiness activities and serve as a subject matter expert during audits.
Oversee developmental and delivery of regulatory reports and deliverables.
Serve as a clinical regulatory resource supporting oversight of delegated vendors performing UM, Appeals, and Grievances functions.
Monitor vendor compliance with federal, state, and accreditation requirements.
Review and validate vendor policies, procedures, workflows, and member communications.
Support vendor audits and regulatory reviews.
Identify and escalate compliance risks and assist with corrective action plans.
Conduct audits of UM and AG activities to assess compliance with regulatory and internal requirements.
Document audit findings, support remediation efforts, and track follow-up actions.
Collaborate with compliance, operations, quality, and analytics partners to evaluate findings and drive corrective actions.
Prepare clear summaries, analyses, and recommendations for leadership review and decision-making.