Network Regulatory AVP

GENERAL DESCRIPTION: Network Regulatory AVP is responsible for providing strategic and operational leadership for the provider contracting, credentialing, recredentialing, and regulatory governance functions within Network Management. Oversees regulatory compliance, audit readiness, provider data integrity, operational performance, and process optimization activities related to the administration of the participating provider network to ensure compliance with federal, state, accreditation, and contractual requirements while supporting efficient provider onboarding, maintenance, and network operations. ESSENTIAL FUNCTIONS: • Leads provide contracting, credentialing, recredentialing, and provider data management operations to ensure efficient and compliant network administration. • Oversees credentialing and provider enrollment processes to ensure compliance with federal, local (CMS, OCS, ASES), accreditation (NCQA), and contractual requirements. • Directs regulatory audits, compliance reviews, and corrective actions to mitigate risk and maintain audit readiness. • Drives operational efficiency, process improvement, and automation initiatives to enhance onboarding, turnaround times, and overall network performance. • Establishes and monitors KPIs, SLAs, and operational dashboards to assess performance, identify risks, and support decision-making. • Ensures implementation of operational controls, policies, SOPs, and governance frameworks for standardized and compliant execution. • Collaborates cross-functionally (Compliance, Legal, Medical Management, Provider Relations, IT) to support regulatory and operational initiatives. • Provides strategic oversight on regulatory requirements impacting network operations, including Network Adequacy, MHPAEA/NQTL, Transparency in Coverage, NSA, and provider data integrity. • Leads resource planning, prioritization, and vendor management to ensure operational continuity and execution of initiatives. • Represents Network Management in executive forums, audits, and cross-functional initiatives, providing strategic guidance and risk mitigation. ADDITIONAL FUNCTIONS: • Supervises, monitors, trains, evaluates, and corrects personnel among others to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions and that they behave according to the policies, standards, norms, and procedures of the Company. • 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 Public Health, Health Services Administration, Business Administration, or related areas. At least eight (8) years of experience in healthcare compliance or operational process optimization, driving performance improvement initiatives within complex and highly regulated healthcare insurance environments. Proven experience in applying structured problem-solving, root cause analysis, and continuous improvement methodologies to enhance operational effectiveness. At least five (5) years of experience supervising personnel. “Proven experience may be replaced by previously established requirements.” Certifications / Licenses: A valid Project Management Professional (PMP) certification or Lean Six Sigma certification is preferred. Other: Knowledge of audit practices, corrective action plans, and compliance monitoring in healthcare operations. Knowledge of data quality standards and best practices for maintaining accurate, audit-ready records. Languages: Spanish – Advanced (comprehensive, writing and verbal) English – Advanced (comprehensive, writing and verbal)