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Provider Network Manager

Provider Network Manager

TriWest Healthcare AlliancePhoenix, AZ
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Job Summary

Develops and maintains provider relationships within designated state / territory, inclusive of relationships with both TriWest Network Subcontractors and any directly contracted provider groups. Manages network development activity with network subcontractors / network providers to ensure network meets all access standards. Provider network includes hospital, physician and ancillary service agreements. Provider Network Manager ensures adherence with government operational manuals, monitors network access, and resolves access issues throughout the assigned region. Facilitates resolution of escalated provider issues, and promotes TriWest Corporate initiatives. Ensures that Network Subcontractors fulfill all performance obligations defined in their Health Network Agreement.

Education & Experience

Required :

  • Bachelor's degree in Business, Health Care Administration or equivalent experience
  • 2+ years of experience managing large or complex provider networks
  • 5 years of experience in a Managed Care or equivalent health care environment
  • 2+ years of experience managing provider contracts including pricing, discounts, and all associated terms and conditions

Preferred :

  • Experience in provider contracting for government programs and / or commercial lines of business
  • Has established relationships and resides in the market for the which the position is located
  • Management experience in the healthcare industry
  • Experience in utilizing a contract management system to manage contracting workflow
  • Negotiation experience
  • Understanding Claims issues and terms

    • Key Responsibilities

  • Maintains relationships with Network Subcontractors in state / market of operations.
  • Develops negotiation strategies for areas of responsibility to achieve individual and department performance metrics.
  • Develops strategic plan to meet network adequacy needs for areas of responsibility and submits to department leadership for inclusion in overall network development plans.
  • Coordinates with Federal stakeholders to deploy network solutions to adhere to requirements of the contracts held by TriWest.
  • Collaborates with Federal stakeholders to identify areas of provider training and education to be incorporated into the TriWest provider education plan.
  • Aligns with Network Subcontractors and Federal Stakeholders to identify areas of opportunity for deployment of alternative payment models to support TriWest’s network and improve health care outcomes.
  • Collaborates with internal leadership team to address network access.
  • Supports providers as needed, with issues related to claims, referrals, or any other program related activity.
  • Demonstrates and maintains current knowledge of all programs, contracting, credentialing, reimbursement and operational policies and TriWest initiatives, operations, and goals.
  • Reviews systems / work flow processes and procedures to identify / recommend opportunities for productivity and process improvement.
  • Collaborates closely with other department leadership, staff, and executive leadership on process improvement to promote service level improvements or facilitate new processes.
  • Monitors and responds to network shortfalls within region through coordination with network subcontractors where appropriate.
  • Regularly reviews and determines appropriate network access and development and makes recommendations to support network build activities.
  • Provides regular updates to department leadership regarding provider network development, management, and access for assigned areas.
  • Communicates information regarding market needs, competition, and industry trends to management team.
  • Proactively manages provider networks in assigned areas and functions as primary internal spokesperson on network issues.
  • Regularly meets with network subcontractors / network providers to inform partners about progress towards agreed-upon goals and upcoming network enhancements; coordinates account planning and maintenance issues.
  • Performs other duties as assigned.
  • Regular and reliable attendance is required.

    • Competencies

    Communication / People Skills : Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

    Computer Literacy : Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

    Empathy / Customer Service : Customer-focused behavior; helping approach, including listening skills, patience, respect, and empathy for another's position.

    Independent Thinking / Self-Initiative : Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.

    High Intensity Environment : Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

    Leadership : Successfully manage Network Subcontractor relationships and associated contracts; takes accountability and follows through on service related requests. Responds with an appropriate sense of urgency.

    Organizational Skills : Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

    Technical Skills : Working knowledge or familiarity with Managed Care, State and Federal health care programs (e.g. Medicaid, Medicare, TRICARE, VA Community Care Network), and the insurance industry; skill in diplomacy and negotiation; skill in financial analysis to analyze contractual reimbursement; skill in project management; skill in presentation; proficient with Excel.

    Team-Building / Team Player : Influence the actions and opinions of others in a positive direction and build group commitment.

    Working Conditions

    Working Conditions :

  • Availability to work non-regular hours as necessary
  • Works in a hybrid environment, with travel as needed
  • Must be able to obtain security clearance as required by government contracts
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