Program Manager UM Regulatory Compliance

Dignity Health Management Services • Bakersfield, CA

1d • $43 - $64 • Remote

About The Position

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.
One Community. One Mission. One California

Requirements

• Five (5) years experience participating in audits, reviewing and documenting policies and procedures
• Bachelors degree
• Experience in reviewing and interpreting regulatory requirements
• Working knowledge of Knox-Keen, DMHC and CMS rules for Claim Submission, Claim Payment, Eligibility, Appeals for Commercial, MediCare and MediCal lines of business
• Guidance and working with others to determine and recommend appropriate process change or process implementation
• Proven ability to work with other business functions to determine operational impact, recommend best practice and articulate to leadership

Nice To Haves

• Ability to create workflow documents (such as using Lucidcart or Microsoft Visio application), create DLPs (Desktop level procedures; i.e. documenting the workflows to be used for training and staff references) experience is a plus
• Document management/version control experience strongly preferred
• Experience with Google Workspace and Microsoft Office preferred

Responsibilities

• Oversight of delegated audits related to the UM, Credentialing, Claims, Enrollment, and Appeals process, in coordination with DHMSO Compliance, to ensure consistent implementation of contractual obligations between CommonSpirit Health / Dignity Health Compliance and our payers related to the services provided by DHMSO Operations.
• Educate staff, update policies and procedures and workflows to maintain ongoing compliance.
• Act as a liaison between the payers and local market leadership.
• Be involved in payer audits, and oversee audit corrective action plans as needed, tracking action plan progress where indicated.
• As All Plan Letters (APL's), CMS memos and other communications are received from governing entities, work with the operational business unit leaders to operationalize and document the process (workflow, desktop level procedures (DLP) impact), and communicate changes with upstream and downstream teams.
• Subject matter expert on all state and national regulatory bodies for supporting all departments and align policies and workflows as needed.
• Oversee regular local auditing to ensure consistent and ongoing compliance to regulations including development of action plans to close gaps and improve overall audit results.
• Maintain, in partnership with the Operational leaders, all Operational policies and program descriptions to confirm alignment with regulatory body updates.
• Work with the staff education team on annual regulatory compliance training required by governing bodies and delegated vendors.
• Work proactively with leadership to assist in activities related to audits.
• Assist local leadership and contracting teams with contract delegation.

Benefits

• As a remote employee, we will provide you with the equipment needed to work from home, including a laptop, docking station, dual monitors, and accessories.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level