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Provider Network Manager - MCO
Job Code:2019-90-001
Department:900 Infrastructure Development
FT/PT Status:Regular Full Time
Salary Minimum79,601
Salary Midpoint99,502
  
Position Closes:
Open Until Filled 

Job Responsibilities & Qualifications:

Job Summary

The Provider Network Manager will report to the Tribal Option Director of the Cherokee Indian Hospital Authority (CIHA). The Provider Network Manager, under the leadership of the Tribal Option Director, and following a matrix team model, will be responsible for developing and managing the operations of a healthcare provider network in accordance with all North Carolina Department of health and Human Services’ requirements and provider network requirement found with 42 CFR 438 governing managed care operations and as outline in the NC Department of Health and Human Services Prepaid Health Plan contract.

 

The position must work collaboratively across the organization to develop the CIHA provider network strategy plan to ensure that the Tribal Option network of enrolled providers is adequate to meet contractually defined network adequacy standards and delivers high quality healthcare services to all members of the Eastern Band of Cherokee Indians. The position is responsible for establishing and maintaining processes and systems related to provider network development including contract management, credentialing and monitoring. Oversees network recruitment, performance and compliance with applicable contract standards. Additionally, the position recruits, hires, trains, and measures performance of staff. May be involved with the design and operations of database systems used to manage provider data and produce reports related to network adequacy and program outcomes.

 

Essential Duties and Responsibilities

Administration:

  • Under the direction of the Tribal Options Director ensures that the guiding vision, mission and values are incorporated into development and operations of the Tribal Option’s network management plan and division.
  • Provides direct supervision to Provider Network Contract Specialist and staff assigned to network operations.
  • Develops in collaboration with other leadership members, statistical, data and management information reports to analyze and evaluate effectiveness and value outcome of provider delivered services.
  • At the direction of their supervisor, educates the Tribal leaders, the community, and key stakeholders on the mission and functions of the Tribal Option.
  • Maintains an effective organizational structure and communication flow that ensures that leadership staff have the necessary information and capacity required to manage in a highly complex, at-risk, regulatory environment.
  • Provides leadership, supervision, and professional growth opportunities to direct reports.
  • Ensures network management functions achieves readiness to obtain national accreditation for health plan management functions and develops and maintains infrastructure and systems to monitor ongoing compliance with standards. Once the Tribal Option is in operations, will work collaboratively with Leadership Team to maintain maximum EQRO compliance.
  • Monitors effective network performance and compliance as it relates to all Medicaid, local, State, and Federal laws, and regulations.
  • Ensures provider-contracting process is executed in compliance with terms and conditions of DHHS Tribal Option Contract.
  • Prepare reports as required and requested.
  • In conjunction with the CIHA Medical Director establishes quality standards and review process to evaluate all providers who have been successfully credentials and re- credentialed thought the state centralized credentialing agency, prior to executing contracts.
  • Serves as the primary point of contact for the states Credentialing Vendor.
  • Develops and implements provider appeals process in accordance with NC Department of Health and Human Services PHP contract.

 

Fiscal and Business Management:

  • Works collaboratively with the Tribal Options Finance Director to establish and monitor the annual department level budget.
  • Assists with the development of analytic reports to help identify provider practice patterns that are outliers.
  • Investigates, develops and recommends new practice models and providers for network inclusion.
  • In collaboration with clinical, finance and quality management staff develop strategy to maximize provider performance and recommends innovative provider relationships that promote strong provider performance, pay for performance and value-based contracting.

 

Network Functions:

  • Manages and oversees the administrative activities of Tribal Option provider contracting to include official correspondence with providers, provider education and liaison, and administration of provider contracts.
  • Under the direction of the Medical Director establishes the network development plan.
  • In collaboration with Quality Management conducts annual evaluation of the network development plan.
  • Ensures the completion of an annual gap and needs assessment.
  • Develops policies and procedures that ensure health care provider have been credentialed and contracted prior to serving EBCI members.
  • Solicits provider participation in the network and conducts re-contracting efforts as needed.
  • Serves as a communication link between network providers and the CIHA
  • Participates in provider rate negotiations.
  • Routinely reviews network accessibility and implements corrective action as needed.
  • In collaboration with Quality Management reviews provider grievance and complaints and implement action as needed.
  • Ensures members are informed of all significant changes within the provider network at least 30 days prior to implementation whenever possible.
  • In collaboration with Compliance and Clinical Operations, implements procedures to ensure member continuity of care when a provider leaves or is terminated from the network.
  • In collaboration with clinical operations coordinates provider training and ensures providers have access and are knowledgeable CIHA approved clinical guidelines.
  • Establish, implement and oversee a provider-monitoring program in accordance with NC DMA and national accreditation standards.
  • Develop single-case agreement/out of network agreement process and monitor utilization of out of network providers.
  • As part of the network evaluation process, establishes comparative cost and quality reports and shares reports with network providers.
  • Creates and submits network adequacy exclusion to NC DHHS.

 

 

 

Supervision Received

The employee exercises a moderate degree of independence; may consult with the Tribal Option Director, Medical Director, Legal and other Directors in resolving issues and maintaining consistency and continuity across agency operations.

 

Personal Contacts

The personal contacts are with, subordinates, co-workers, higher ranking managers, leadership of outside entities, network providers, patients, and members of the community. The purpose of the contacts are to exchange information, resolve contracting issues, improve care, and resolve differences between subordinates.

 

Education/Experience/Minimum Qualifications

  • Bachelor’s degree in BS/BA Reguired.
  • Minimum five (5) years’ experience in network operations or provider relations management. Preferably, management experience in: health insurance, managed care, or IPA/PHO.
  • Knowledge of Medicaid managed care and previous work with tribal health care is preferred.

 

Other Requirements:

  • Strong verbal, written and interpersonal skills a must.
  • Excellent organizational skills with strong attention to details.
  • Proven ability to solve problems and make sound decisions.
  • Ability to work collaboratively with cross-functional agency units and departments.
  • Ability to work independently and within a team environment.
  • Ability to function effectively within an ever-changing environment to meet deadlines and prioritize as necessary.
  • Proficiency in MS Office and database tools.

 

Other

Incumbent is responsible for insuring that active EEO and Affirmative Action Programs emphasizing Indian Performance, the EEO Act of 1972 and the OCAO/IHS Area Policy Statement in EEO are in place. Must also insure subordinates have free and confidential access to information about EEO and affirmative action. Submits reports on EEO matters in a timely and efficient manner.

 

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by displaying Language of Caring behaviors and skills. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service. Embraces role models and implements all elements of our customer service program. Partners and coordinates with other departments to ensure total patient/customer satisfaction and efficient operations in a safe, friendly, comfortable environment, by well- trained, motivated employees. Recommends and implements change to improve overall patient/customer satisfaction. Performs all tasks, including interactions with network providers, in accordance with the mission, values and principles of the Right Way.