Manager- Provider Network Operations

Presbyterian Healthcare Services; Albuquerque (NM); On-site; USD 76,000 - 129,000; Full time

Job summary

Presbyterian Healthcare Services in Albuquerque, NM is seeking a Manager of Provider Network Operations to lead the provider network team, recruit providers, and ensure contract compliance. You will mentor staff, coordinate complex issues, and drive network optimization for access and affordability.

The role focuses on education, engagement, and collaboration with providers, while aligning with Medicare/Medicaid guidelines and PHP strategies. Travel regionally to meet providers as needed.

Qualifications

• Bachelor's 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.
• Two years management experience preferred.
• 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.

Responsibilities

• Manages and oversees all aspects of Provider Network Operations to accomplish goals.
• Establishes and maintains strong relationships with the provider community.
• Ensures access to quality health care for health plan beneficiaries.
• Meets enterprise goals of affordability and fiscal sustainability.
• Oversees daily operations, ensuring smooth and compliant operations.
• Facilitates provider questions and support.
• Resolves complex provider contracts and reimbursement issues.
• Researches problems and negotiates with internal/external partners to resolve issues.
• Oversees monthly departmental KPI reporting.
• Reviews contracts to ensure policy compliance.
• Develops and maintains provider networks, including recruiting new providers.
• Ensures compliance with federal, state, and organizational regulations.
• Manages sensitive contractual matters with discretion and confidentiality.
• Ensures team adheres to policies and standards.
• Keeps team focused on goals and removes barriers to success.
• Acts as a point of contact for solution delivery matters.
• Monitors and audits processes and workflows to maintain performance.

Skills

Leadership

Communication

Coaching

Conflict management

Multi-tasking

Team collaboration

Travel readiness

Education

Bachelor's degree in business administration or related health care field

Job description

Location Address:

9521 San Mateo NE Albuquerque, NM 87113-2237

Compensation Pay Range

Minimum Offer $75,732.80 Maximum Offer $128,960.00 Now Hiring: Manager- Provider Network Operations

Summary

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. Type of Opportunity: Full time Job Exempt: Yes Job is based: Reverend Hugh Cooper Administrative Center Work Shift: Days (United States of America)

Responsibilities

• Manages and oversees all aspects of Provider Network Operations as is necessary to accomplish:
• Establishing and maintaining strong relationships with the provider community.
• Ensuring access to quality health care for health plan beneficiaries.
• Meeting enterprise goals of improving affordability and fiscal sustainability.
• 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.

Qualifications

• 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.
• Two years management experience preferred.
• 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.

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness

Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services

Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services