Manager- Provider Network Operations

Presbyterian Healthcare Services

1d•$75,733 - $128,960•Onsite

About The Position

Ensure the integrity of provider service, contracting, and development of new networks. Build and maintain strong relationships with providers to foster collaboration and improve communication. Educates providers with current and new protocols, policies, and procedures. Provides leadership to the department staff whose focus is education, support, engagement, fostering relationships while recruiting providers. Acts as a key resource in mentoring and education of staff. Responsible for identifying issues, resolving and coordinating resolution of complex disputes or issues. Contributes to the overall optimization of the provider network, ensuring adequate access and coverage for members. Manages and coordinates assignments and work productivity of supervised staff. Provides leadership and assistance to Supervisor, Trainer, Provider Executives, and Provider Associates of Provider Network Operations. Provides direction and support for ensuring successful execution of contract compliance with Presbyterian Health Plan policy as well as compliance with applicable Medicare, Medicaid and other third-party guidelines. Executes Presbyterian Health Plans network development strategies and initiatives.

Requirements

Bachelors degree in business administration, or related health care field, 6 years of additional experience can be substituted in lieu of degree.
Three years experience in provider relations, provider contracting, claims processing, correct coding, and customer service in a managed care organization.
Four years of application specific experience.
Requires effective coaching, counseling, and conflict management skills.
Must be able to work collaboratively with other employees and the ability to multi-task.
Demonstrated ability to sustain quality standards.
Demonstrated ability to communicate in verbal and written form with peers, subordinates and the public, including physicians, physician office staff and staff.
Ability to handle fluctuating workloads, conflicting priorities, and concurrent activities.
Regional travel is required to meet with providers for purposes of recruitment, re-contracting, provider education, and/or attendance for any provider related functions.

Nice To Haves

Two years management experience preferred.

Responsibilities

Manages and oversees all aspects of Provider Network Operations as is necessary to accomplish: a) Establishing and maintaining strong relationships with the provider community. b) Ensuring access to quality health care for health plan beneficiaries. c) Meeting enterprise goals of improving affordability and fiscal sustainability. d)Meeting health plan standards regarding operational administration.
Oversee the daily operations of a healthcare provider network, ensuring smooth and compliant operations.
Facilitate positive relationships with providers, addressing their questions, concerns, and providing support.
Resolves complex provider contracts and reimbursement issues. Research problems and negotiate with internal/external partners/customers to resolve highly complex and/or escalated and sensitive issues. Identifies necessity for additional escalation and communicates issues effectively to senior leadership.
Oversee compliance, oversight, and reporting of monthly departmental key indicators.
Reviews and explains contracts with healthcare providers, ensuring compliance with organizational policies and regulations.
Actively develops and maintains a robust provider network, including recruiting and onboarding new providers.
Ensures that all network activities comply with relevant federal, state, and organizational regulations.
Develops and manages new and existing provider networks in support of PHP strategies while exercising discretion, as appropriate, with sensitive contractual matters, while maintaining confidentiality.
Ensure team members perform tasks in accordance with established department and organization policies and standards.
Ensure team is focused on appropriate goals and removes barriers to success
Acts as a point of contact, liaison and escalation for all team solution delivery matters.
Ensure that performance standards are being maintained by performing ongoing monitoring and audits of processes and workflows.