Provider Network Manager

The Provider Network Manager leads the development and maintenance of a robust provider network, including ongoing efforts to evaluate and improve network access, cost, and quality. The Provider Network Manager oversees the design, implementation, and maintenance of provider payment models including Value Based Payment Models. They lead network development, improvement, engagement, and training efforts, including leading learning collaborative programs, and maintaining relationships with provider executives. The Network Manager champions new analytics provider related initiatives and support data integrity initiatives. They also drive continuous improvement of Provider Services’ departmental operations. This role requires unflagging intellectual curiosity, an analytics approach to problem solving, and a high level of enthusiasm for cross-departmental collaboration.

Position overview
• Oversee provider network operations, including data sharing, provider onboarding, network development and maintenance, the design and implementation of provider education materials, provider training, and provider relationship management.
• Lead operational process improvement efforts within Provider Services and across departments to optimize the provider experience with HPSM departments, processes, and requirements. Participate in inter-departmental groups that focus on improving access to care and quality of care.
• Identify and drive network development and expansion priorities based on network adequacy and access needs.
• Oversee strategy development for Provider Learning Collaboratives with network providers, to advance health outcomes, manage cost, improve members’ experience of care, and provider satisfaction and experience. Work in partnership with team members who have direct responsibility for specific collaborative program implementation.
• Oversee the design and implementation of new payment models and risk arrangements, incorporating evolving industry best practices. Manage and improve existing Value-Based Payment programs, including ongoing program evaluation and revision, informed by internal and external input. Ensure that existing program changes are effectively communicated to a variety of stakeholders including formal Committees. Provide education to HPSM personnel to increase organization-wide understanding of provider payment models.
• Oversee the preparation of financial impact analysis of new and revised payment arrangements; make recommendations and decisions about provider network rates in coordination with the Finance Department.
• Build and maintain executive and operational leader relationships between HPSM and key providers, such as health systems, FQHCs, and select delegated relationships. Lead process improvement work with these key partners. Act as HPSM central point of contact for issue escalation and resolution with key provider groups.
• Serve as department lead on the development, implementation, and maintenance of network analytics initiatives, including provider scorecards / quality data sharing, network adequacy assessments, regulatory network reporting, and other HPSM priority analytics functions.
• Support strategic planning and play a lead role in design decisions for new provider systems and system enhancements. Support adoption of new technology and data sharing processes, and ensure that provider-facing information systems maximize the provider user experience.
• Ensure HPSM network adequacy compliance, implementing corrective action as needed throughout the year to improve network performance and acting as lead for regulatory submissions. This includes overseeing compliance with DMHC Timely Access, and DHCS and CMS network adequacy requirements. Partner with Provider Services Operations Manager on work related to NCQA accreditation.
• Lead regulatory response activities for NCQA, DMHC, DHCS, and CMS, for requirements related to HPSM’s network, relevant policies and procedures, and payment arrangements.
• Diplomatically and creatively resolve escalated or complex provider network issues, using strong problem-solving and communication skills and approaching conflict resolution with humble curiosity and a bias to action. Ensure the resolution of escalated provider grievances, appeals, and Potential Quality Issues (PQIs) taking corrective action with providers as needed.
• Accomplish staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching, counseling, and implementing corrective action steps when necessary; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards. Complete performance evaluations in a timely manner.

These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply.

Education and experience
• Bachelor’s degree in a related field. Master’s degree in related field strongly preferred.
• Managed care contracting experience in a healthcare environment dealing directly with payers, providers, and intermediaries.
• Experience implementing and managing delegated entity agreements with multispecialty groups, County agencies, and other provider/vendor types.
• Experience with value-based payment models within a health plan or health system setting.
• Experience performing financial analysis and quality improvement activities.
• Experience interpreting and implementing state and federal network adequacy and access requirements and reporting.
• Experience leading data integrity and analytics efforts.
• Experience managing/supervising (4 years or more preferred).

Knowledge of:
• Medicare and Medicaid regulations and managed care operations.
• Provider payment methodologies and processes, including value-based payment and provider billing and payment processes.
• In-depth knowledge of Medicaid and Medicare reimbursement methodologies, fee schedule development, utilizing financial models and analysis in developing provider payment rates and risk-sharing arrangements, and knowledge of claims processing systems and other health plan managed care systems.
• State and federal network adequacy and access requirements and reporting.
• Project management and process improvement methodologies.
• Quantitative reasoning and analytics tools
• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
• Supervisory principles and practices as well as techniques and methods to organize, manage, and develop direct reports.

Ability to:
• Maintain accountability for network expansion targets and specific medical cost initiatives.
• Organize priorities as needed and meet reporting and program deadlines.
• Develop strategies for network development and access.
• Work cross-functionally to execute network strategies.
• Establish and maintain excellent relationships with providers across levels of seniority.
• Understand complex data maintenance logic and provide recommendations to improve data integrity.
• Derive insights from analytics and use these to drive improvements to HPSM’s provider network.

Salary and benefits

The starting salary range depends on the candidate’s work experience.

Excellent benefits package includes:
• HPSM-paid premiums for employee’s medical, dental and vision coverage (employee pays 10% of each dependent’s premiums)
• Fully paid life, AD&D and LTD insurance
• Retirement plan (HPSM contributes equivalent of 10% of annual compensation)
• 12 paid holidays a year, 12 paid sick days a year and paid vacation starting at 16 days a year
• Tuition reimbursement plan
• Employee wellness program

To apply, submit a resume to

Health Plan of San Mateo (HPSM) is a local County-funded nonprofit manages the health care for over 140,000 low-income people San Mateo County, including all its Medi-Cal eligible residents. HPSM is proud to be an Equal Opportunity Employer and an affirmative action employer. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status.

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