Manager- Provider Network Operations

0100 PHP Administrative; United States; On-site; USD 76,000 - 129,000; Full time

Job summary

Presbyterian Healthcare Services seeks a Manager- Provider Network Operations to lead the provider network team, ensure contract compliance, and drive initiatives across PHP networks. You will build relationships with providers, educate on policies, and mentor staff while coordinating complex disputes and ensuring access for members.

The role requires leadership, travel to meet providers regionally, and a strong background in managed care operations within a large health system.

Qualifications

• Bachelor's degree in business administration or related health care field; 6 years experience may substitute for degree.
• Three years in provider relations, provider contracting, claims processing, correct coding, and customer service in managed care.
• Four years of application-specific experience; two years of management preferred.
• Coaching, counseling, and conflict management skills are required.
• Ability to multi-task and collaborate across teams; strong communication required.
• Willingness to travel regionally to recruit, re-contract, and educate providers.

Responsibilities

• Oversee all aspects of Provider Network Operations to build provider relationships.
• Ensure access to quality care and meet enterprise affordability and sustainability goals.
• Oversee contract compliance with PHP policies and regulatory guidelines.
• Lead and mentor staff; assign work and monitor productivity and KPIs.
• Develop and maintain the provider network; recruit and onboard providers.
• Resolve complex provider contracts and reimbursement issues; escalate as needed.
• Coordinate resolution of issues with senior leadership and stakeholders.
• Ensure regulatory compliance of network activities and reporting.

Skills

Leadership

Coaching

Conflict management

Communication

Multi-tasking

Education

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

6 years experience substitute for degree

Three years provider relations/contracting experience

Two years management experience preferred

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: 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.

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

Here, we’re committed to a different way to make a difference. Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, nurses, employees, board members, and volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than one in three New Mexicans. We are part of New Mexico's history and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.