Provider Network Program Manager – Cost Calculator

About the role

This role is responsible for end-to-end program management, operational execution, and compliance support for Medica’s Cost Calculator tool and associated data.

Responsibilities

• Lead Cost Calculator Operations & Program Execution
• Manage implementation of new and updated products, services, and integrations (e.g. WebTPA migration, APR-DRG additions, enhancements to tool functionality)
• Coordinate user acceptance testing (UAT) and validate successful system and data changes
• Oversee transition initiatives (e.g., single search experience) and ensure delivery against timelines
• Partner with IT, vendors (e.g., Kyruus Health), and internal stakeholders to execute roadmap items
• Ensure Ongoing Compliance & Regulatory Alignment
• Support compliance with Transparency in Coverage (TiC) and CMS requirements, including large-scale regulatory updates
• Maintain required disclosures (preventive, prior authorization, step therapy, etc.) and ensure accuracy and legal appropriateness of published information
• Monitor regulatory changes and translate requirements into operational and system updates
• Partner with compliance and legal teams to mitigate risk and support audits or inquiries
• Ongoing Maintenance & Data Integrity Oversight
• Monitor and maintain provider and cost data feeds to ensure accuracy and completeness, including alignment of provider data to Cost Calculator requirements and changes resulting from source system replacements
• Manage updates to negotiated rates, provider information, and code sets (e.g., CMS code updates)
• Identify and drive resolution of data discrepancies and support root-cause analysis
• Maintain relationships with delegated entities and partners (e.g. Optum, UHC, leased networks) to ensure data quality
• Drive Program Coordination, Reporting & Stakeholder Engagement
• Lead recurring operational meetings, status reporting, and cross-functional coordination (IT, digital, compliance, operations)
• Compile usage metrics and provide insights to support decision-making and roadmap prioritization
• Develop and obtain required approvals for business cases, risk assessments, and business decision documents as needed
• Serve as a key point of contact for vendor and internal leadership communications including vendor’s regular product reviews and roundtables
• Manage the library of previous documentation of the initiative
• Support Issue Resolution & Continuous Improvement
• Triage and drive resolution of member and operational issues related to the Cost Calculator experience
• Support customer service teams with current and future tool-related inquiries and workflows (live over the phone estimates)
• Identify process improvements and automation opportunities to increase efficiency and reduce errors
• Contribute to training, documentation, and change management efforts

Requirements

• Bachelor's degree or equivalent experience in related field
• 7+ years of related work experience beyond degree

Preferred Qualifications

• Strong project and program management skills with the ability to lead complex, cross-functional initiatives from planning through implementation
• Working knowledge of CMS regulations, healthcare compliance requirements, and other regulatory standards impacting provider network and cost transparency initiatives
• Ability to assess downstream impacts of strategic, operational, and technical decisions across members, providers, business teams, and systems
• Strong critical thinking and problem-solving skills with the ability to evaluate broad organizational implications and identify potential risks, dependencies, and opportunities
• Ability to effectively translate business needs into technical requirements and communicate complex technical concepts to non-technical stakeholders
• Working knowledge of healthcare claims processing and adjudication concepts, including provider reimbursement methodologies and claim modifiers
• Experience collaborating within a matrixed organization and influencing outcomes across multiple departments, teams, and stakeholders
• Strong relationship-building, communication, and stakeholder management skills, with the ability to partner effectively across business and technology functions
• Strong organizational skills with the ability to manage competing priorities in a fast-paced environment