Manager, Provider Network

Sutter Health • Los Altos, CA

2d

About The Position

Oversees the daily operations of the provider network contracts and information for Sutter Health. Administers, negotiates, and supervises managed care provider networks that offer health care services to commercial Health Management Organizations (HMOs), Medicare Advantage, and health plan members linked to Sutter-recognized primary care physicians. Maintains an organizational structure that meets the service, financial, and informational requirements of both internal and external customers. Creates and maintains a provider database to enable accurate claims processing and provider directories. Manages interactions between providers, the health plan, medical groups, risk bearing organizations (RBOs) and other Sutter Health provider data resources in the support of Commercial and Medicare business lines. Designs, oversees, and performs analytical projects to support operations initiatives and assists with network, operations and care management business project initiatives that further the advancement of strategic goals set forth by Sutter Health.

Requirements

• Bachelor's: Business Administration, Health Administration, Health Education, Social Work, or related field
• 8 years recent relevant experience
• In-depth knowledge of health care contracting terminology and language, requirements, provisions, managed care risk contracting, and various reimbursement methodologies to support the development and maintenance of contract compliance, language review, and analysis.
• Familiarity with and understanding of California Department of Managed health Care (DMHC) regulations, various health care reimbursement models, pricing mechanisms, managed care and payer relationships.
• Knowledge of the structure of health care business including Health maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) as well as Employee Retirement Income Security Act (ERISA) products.
• Demonstrated knowledge of health Insurance Portability and Accountability Act (HIPAA), Health Care Reform, Business Code of Ethics, and government regulated programs.
• Analytical and problem solving skills with the ability to determine organizational needs and to achieve corporate goals and financial objectives.
• Exceptional project management and organization skills, including the demonstrated ability to manage and complete multiple complex projects simultaneously on time and within budget.
• Advanced business acumen; financial expertise, solid consensus building skills, in addition to being an effective decision maker, influential negotiator, and expert delegator.
• Expert communication (written and verbal) and interpersonal skills, presentation and negotiation competencies with the ability to lead, provide recommendations, resolve conflict, and influence decision making.
• Proficient computer skills, including advance competency in Microsoft Office suite, Microsoft Visio, and a solid understanding of internet research, database management, and data accuracy verification techniques.
• Operate independently, confidentially, and to garner confidence from staff, Sutter Health affiliates, and leadership.
• Identify and resolve technical, operational and organizational problems using policies, procedures and department plan.
• Negotiate effectively with staff, senior management, vendors, state and federal agencies, and industry organizations.
• Foster a collaborative environment, to influence individuals or groups with diverse opinions and to enlist cooperation without direct control/authority.
• Establish, build, and maintain collaborative and effective working relationships with peers, stakeholders, executives, diverse individuals and organizations, and regulatory agencies.

Responsibilities

• Oversees the daily operations of the provider network contracts and information for Sutter Health.
• Administers, negotiates, and supervises managed care provider networks that offer health care services to commercial Health Management Organizations (HMOs), Medicare Advantage, and health plan members linked to Sutter-recognized primary care physicians.
• Maintains an organizational structure that meets the service, financial, and informational requirements of both internal and external customers.
• Creates and maintains a provider database to enable accurate claims processing and provider directories.
• Manages interactions between providers, the health plan, medical groups, risk bearing organizations (RBOs) and other Sutter Health provider data resources in the support of Commercial and Medicare business lines.
• Designs, oversees, and performs analytical projects to support operations initiatives and assists with network, operations and care management business project initiatives that further the advancement of strategic goals set forth by Sutter Health.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 11-50 employees