Manager of Provider Operations

Company Name:
manages all aspects of the provider network for an assigned geographic area, usually encompassing multiple states. The primary responsibilities for a Network
include negotiating rates and contractual terms with providers in assigned territory, ensuring adequate provider access by maintaining market depth and breadth, and ensuring high levels of provider satisfaction. Expected to build a high level of localized market expertise specific to assigned geographic region. Key interface between Network Operations and internal RCC Operations teams.
Primary Responsibilities:
Abides by and demonstrates the company Mission - Vision - Values through both behavior and
performance on a day-to-day basis.
Manages all aspects of provider network for an assigned geographic territory, usually encompassing multiple states.
Manages provider recruitment, ensuring adequate provider access for Plan members. Reviews/analyzes local, regional and national network proposals and/or contracts and develops provider network for assigned CareCentrix operation center/contract.
Manages and improves quality metrics (PSAs and Manual Authorizations).
Manages and attains gross margin to budgeted levels.
Negotiates reimbursement rates and manages to budgeted rate pool. Negotiates rates and contractual terms with providers in their assigned region. Obtains the best possible rates and contractual terms available in the market while meeting other performance goals.
Manages/participates in provider contract analysis, negotiation, credentialing, training/satisfaction maintenance and data collection/analysis/reporting.
Provides superior level of service to providers, responding to issues and problems in timely manner.
Oversees a regional program of provider profiling/analysis to ensure ongoing financial viability with provider agreements compared to peers within territories and nationally. Reviews annual provider trended rates compared to carrier rates to measure variances.
Provides ongoing support and strategic focus to CareCentrix current and future marketing efforts.
Develops localized market expertise specific to their geographic region including localized geography, provider reputations, strengths and weaknesses, market issues and referral source patterns by establishing a personal presence in the market.
Collaborates and works well with personnel within the PRC teams within the same geographic region.
Maintains relationships with the provider to be able to get the most out of them. Demonstrates ability to work through complex relationship issues, particularly the successful development and execution of action plans to develop specific performance issues.
Develops and executes certain action plans which may involve a sustained provider recruitment plan, the development of preferred relationships, more aggressive rate negotiation, better education to our operations teams etc.
Assists AVP in strategic projects as assigned.
Conducts training sessions and administers provider satisfaction surveys as required.
Adheres to and participates in Company's mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices. Ensures Utilization Management and URAC standards are followed.
Reviews and adheres to all Company policies and procedures and the
Participates in special projects and performs other duties as assigned.
Required Skills:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Required Education / Experience:
Bachelor's Degree plus a minimum of five years experience working with health plans, provider contracting, or managed care setting. Provider Relations and/or provider contracting experience and project management skills a plus. High level of analytical competence and comfort with Excel/Spreadsheet Applications and knowledge of word processing applications also required. Superior communication/negotiating skills necessary. Knowledge of Utilization Management and URAC standards.

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