Network Operations Specialist III

Duties

Advances managed care programs and network initiatives by translating regulatory and program requirements into actionable strategies and measurable outcomes. Leads the planning and execution of key initiatives including Targeted Rate Increase (TRI), Hospital-Directed Payment Programs, and related projects—by structuring work packages, managing milestones, and ensuring completion with clear evidence.

Serves as a cross-functional connector, coordinates workgroups, tracks deliverables, documents decisions, and proactively resolves blockers. Maintains consolidated logs and weekly updates, the role ensures transparency and accountability throughout program execution.

All Plan Letters (APLs) and legislative directives, drafts business requirements, and aligns tasks across teams. Validates adherence, identifies gaps, documents corrective actions, and escalates unresolved risks to uphold compliance. Regulatory review and operationalization are central. Synthesizes

Builds KPIs and dashboards to monitor program health, analyzes trends, flags risks, and prepares concise executive briefings and risk memos for leadership. Performance, data, and risk management are core strengths.

Audit readiness is sustained through rigorous documentation and control evidence. Coordinates Universal Provider Manual (UPM) updates and maintains readiness for California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and National Committee for Quality Assurance (NCQA) reviews.

Acts a reliable point of contact, schedules touchpoints, publishes agendas and notes, and closes action items with stakeholders. Partners with communications to deploy provider notices and adoption campaigns tied to operational changes.

Collaborates with IT and Data teams to translate business requirements into system changes and report specifications, supporting user acceptance testing and production validation.

Apply subject matter expertise in evaluating business operations and processes. Identify areas where technical solutions would improve business performance. Consult across business operations, provide mentorship, and contribute specialized knowledge. Ensure that the facts and details are correct so that the program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provide training and recommend process improvements as needed.

Perform other duties as assigned.

Job Summary

(1 available position)

The Network Operations Specialist III drives managed care program success by translating regulatory and program requirements into actionable strategies and measurable outcomes. This role leads the planning and execution of key initiatives. As a cross-functional connector, the Specialist coordinates workgroups, tracks deliverables, documents decisions, and resolves blockers to maintain transparency and accountability. This role is responsible regulatory review and operationalization, synthesizing directives, drafting business requirements, and aligning tasks across teams.

The Specialist validates process adherence, identifies gaps, and escalates risks to uphold compliance. Supports performance and risk management through KPIs, dashboards, and executive briefings. Audit readiness is Maintains audit readiness through rigorous documentation and coordination of provider manual updates. The Specialist also serves as a reliable point of contact, facilitating stakeholder communication and partnering with IT/Data teams to implement system changes and reporting specifications. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 3 years in managed care/network operations, data analysis, or regulatory operationalization with cross‑functional coordination.

Demonstrated experience executing program plans, interpreting APLs/policy, preparing audit evidence, building KPIs/dashboards, and supporting multi‑stakeholder implementations.

Preferred:

Experience with provider communications/portal adoption and coordinating UPM updates for network changes.

Skills

Required:

Ability to convert program/regulatory requirements into clear tasks, workflows, timelines, and measurable outcomes.

Working knowledge of APLs and network‑related directives; comfort drafting business requirements and implementing controls that demonstrate compliance.

Knowledge of KPI definition, trend analysis, issue/risk logging, and status reporting for leadership consumption.

Proven knowledge and understanding of coordination with Provider Relations, Credentialing, Provider Data, Compliance, Legal, and IT/Data teams to align deliverables and close gaps.

Strong written/verbal skills; ability to assemble concise executive briefings and maintain policy/procedure/workflow documentation and audit artifacts.

Preferred:

Ability to leveraging operational and trend data to identify risks and process improvements in Network Operations.

Knowledge of with DOFR‑based payments, hospital‑directed payments, and alternative payment models to anticipate operational implications. 

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

Required:
Travel to offsite locations for work required.