Network Regulatory Specialist

Network Regulatory Specialist

Regular

Exempt

GENERAL DESCRIPTION:

Supports regulatory compliance through audit readiness, regulatory reviews, corrective action plan management, and monitoring of provider network activities, including contracting, credentialing, and recredentialing. Responsible for monitoring and analyzing metrics, key performance indicators (KPIs), and operational data to identify trends, assess risks, and support adherence to federal, state, accreditation, contractual, and organizational requirements. Collaborate with cross-functional teams to prepare regulatory documentation, support issue resolution, and contribute to continuous improvement efforts that strengthen compliance, mitigate risk, and enhance the effectiveness and integrity of Network Management (NM).

ESSENTIAL FUNCTIONS:

Serve as the primary liaison between NM and Compliance to coordinate the communication, assessment, and operational implementation of regulatory, accreditation, and contractual requirements impacting NM functions.

Evaluate regulatory, accreditation, and business requirement changes affecting provider network operations, conduct operational impact assessments, and coordinate readiness activities to support timely implementation.

Identify, assess, and monitor operational, regulatory, and process risks within NM activities, including provider contracting, credentialing, and recredentialing, and recommend mitigation strategies.

Prepare and present risk assessments, readiness status updates, corrective action progress, and operational findings to NM leadership and other internal stakeholders to support effective governance and decision making.

Facilitate the development, implementation, and monitoring of corrective action plans resulting from audits, regulatory reviews, internal assessments, and identified operational risks to ensure timely and sustainable remediation.

Provide guidance and consultation to NM teams regarding operational implications of regulatory and accreditation requirements, promoting awareness, preparedness, and process consistency.

Partner with NM leadership and cross-functional teams to support regulatory reviews, delegated oversight activities, and compliance-related initiatives by coordinating requests, documentation, and action tracking.

Develop, maintain, and analyze dashboards, scorecards, key performance indicators (KPIs), and operational metrics to identify trends, monitor performance, and support compliance-related decision making.

Monitor credentialing, recredentialing, provider contracting, and other network management operational metrics to identify potential compliance risks, process gaps, and opportunities for continuous improvement.

Coordinate and support audit readiness initiatives by maintaining documentation, evidence repositories, process inventories, and supporting records required for regulatory reviews, audits, and accreditation activities.

Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.

May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience: Bachelor's Degree in Business Administration, Health Services Administration, Public Health, or related fields. At least two (2) years of experience in healthcare regulatory compliance, network management, provider operations, quality management, audit management, or related functions, preferably within the Healthcare Insurance Industry.

"Proven experience may be replaced by previously established requirements."

Certifications / Licenses: Not required.

Other: N/A

Languages:

Spanish Advanced (comprehensive, writing and verbal)

English Advanced (comprehensive, writing and verbal)

"We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities."