Clinical Regulatory Oversight, Program Manager V

Clinical Regulatory Oversight, Program Manager V

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

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.

Key Accountabilities

• Clinical Regulatory Oversight and Implementation
  • 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.
• Letters, Policies, and Procedures
  • 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.
• NCQA and Regulatory Deliverables
  • 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.
• Vendor Oversight and Delegation Support
  • 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.
• Audit, Monitoring, and Cross-Functional Oversight
  • 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.

Required Qualifications

• 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.

Preferred Qualifications

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

This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, St. Louis, MO, or Omaha, NE.

The full salary grade for this position is $100,300 - $172,000. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $100,300 - $150,465. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.