Job Description

In this role as Provider Compliance and Policy Manager, you will manage and coordinate audits on behalf of the Provider Credentialing department. Review and provide complete and accurate documentation and results to auditors and government/regulatory agencies as requested, consult on potential issues, and formulate Wellmark's response. Support timely completion of any recommended actions. Interpret state and federal regulations as well as Blue Cross Blue Shield Association (BCBSA) changes and provide impact to stakeholders regarding changes which may impact Provider Credentialing. Support the management, coordination, and completion of Credentialing regulatory changes and projects. Collaborate and work closely with Legal, Compliance, and Government Relations in the interpretation of regulations in support of business-specific planning and execution. Complete the annual update of department policies and procedures and own the creation of policies/procedures in PolicyTech.

Qualifications

Required:

• Bachelor's degree in accounting or related field or direct and applicable work experience.
• 4+ years of work experience in insurance operations, provider network administration, contracting, credentialing, medical policy, or similar area preferred.
• 2+ years of work experience completing audits or coordinating audits
• Project management or business process experience. Ensures projects meet quality, time, and stakeholder expectations, and effectively manages, competing priorities in a fast-paced, dynamic work environment.
• Demonstrates the ability to review, analyze, and interpret regulations/guidelines and provide insights or recommendations.
• Excellent analytical, research, and critical thinking skills.
• Strong attention to detail. Ability to monitor, collect, or record data and assess its accuracy, validity, or integrity.
• Excellent verbal and written communication skills. Presents and articulates complex information clearly and effectively to a variety of stakeholders, both internally and externally.
• Ability to consult with stakeholders, apply subject matter expertise and influence decisions appropriately.
• Ability to build relationships throughout the organization
• Proficient with Microsoft Office (e.g., Word, Excel, Outlook) and web-based applications (e.g., PolicyTech), with the ability to learn new technology quickly.
• Ability to measure and evaluate work processes and utilize appropriate resources to identify opportunities or implement solutions. Flexible and adaptable to change. Ability to lead others through change.

Additional Information

a. Manage and coordinate internal and external audits; including issue identification, coordination of corrective action plans in accordance with regulatory requirements and federal guidelines.

b. Compile and maintain audit documentation to support audit work performed, conclusions/issues identified and recommendations/ action plans. Develop desk level audit procedures, as necessary, for assigned audits.

c. Accountable for review of all weekly/published regulatory/compliance publications that are received from Compliance team, BCBSA, and other partners impacting Network Administration. Provide insight to the business, and assess impacts, and share information as applicable with business partners.

d. Monitor and analyze new and changing regulatory requirements and assist in aligning change to achieve project objectives. Work with legal area to obtain interpretation of regulations in support of business execution.

e. Proactively review industry best practices and upcoming regulatory changes related to credentialing and contracting. Share information with leadership; prepare for required changes and support implementation of best practices. Communicate any new or changing regulations to Network Administration leadership and team members concisely and timely. Analyze and communicate impact of change.

f. Ensure state and federal regulation related activities are monitored, tracked, and resolved appropriately according to established policies and procedures.

g. Lead Network Administration process for compliance issues, including communication of any self-reported issues and timely remediation of issues or concerns.

h. Recommend and implement policy and solution changes to business processes to enhance and obtain better efficiencies for the department and division.

i. Establish and maintain effective partnerships and perform in the role of liaison between Network Administration and internal stakeholders, including Legal and Compliance, to manage corporate and department project initiatives.

j. Lead any communication needs related to key regulations and Network Administration impacts and collaborate with others to ensure appropriate messaging.

k. Manage annual Compliance deliverables, including the Compliance Risk Assessment and Self-compliance audit process, with Network Administration team and Compliance.

l. Support planning and implementation of Network Administration policy changes utilizing PolicyTech. Own the creation of Policies/ Procedures in Policy Tech.

m. Other duties as assigned.