Provider Network Program Manager – Cost Calculator

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.

This role is responsible for end-to-end program management, operational execution, and compliance support for Medica’s Cost Calculator tool and associated data. The position ensures accurate, compliant, and timely delivery of cost transparency capabilities, including implementation of regulatory requirements, ongoing product enhancements, and coordination across internal and external partners. The role serves as the primary operational lead for sustaining and advancing the tool while supporting enterprise transparency and member experience objectives. Performs other duties as assigned.

Key Accountabilities

• 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) and decommissioning of retired products
  • 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
  • Ensure adherence to Public Facing Machine Readable Files requirements of the Transparency in Coverage Mandate, working with Medica IT and Compliance Teams
  • 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

• Perform 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

Required Qualifications

• 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.

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, or Madison, WI.

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 compensation, 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.

Internal Applicants: We’re excited about your interest in growing your career at Medica! To be eligible to apply for internal opportunities, employees must have been in their current role for at least one year.

Recruiter: Carissa Forcier

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.