Provider Relations Manager

Are you excited to step into a complex world that requires a blend of mind, heart and flexibility? We at CareOregon have been strengthening communities since 1994 by making health care work for everyone. As a nonprofit health plan largely focused on Oregon’s Medicaid population, we find fulfillment in supporting the underserved.

General Statement of Duties
The Provider Relations Manager is responsible for the development, implementation, and management of

strategy and measurable goals to support the professional and specialty provider networks, whichprovides optimized access to healthcare services for CareOregon members. This role manages and directs the Provider Relations team, which is responsible for developing, maintaining and supporting effective relations with the provider community to enhance provider satisfaction. Also, it serves as the primary provider contact for larger providers and groups in CareOregon’s delivery system. This role manages and oversees the required regulatory reporting and auditing functions that ensure appropriateness and adequacy of CareOregon network.

Essential Position Functions
Develop and mentor Provider Relations Specialists to ensure providers obtain concise and accurate information on both Oregon Health Plan and Medicare Advantage benefits and policies.
Develop and revise policy and procedures related to Provider Relations; including recommending and implementing new methods to improve provider education and support.
Collaborate with major provider networks within CareOregon’s service area to develop and support community-based delivery of health care services in conjunction with Lines of Business (LOB) leadership, Network and Clinical Support (NCS) peers and other CareOregon teams.
Responsible for coordination, completion and timely submission of Delivery System Network (DSN). This includes routine review, reporting and communication coordination for all LOB’s including CCO’s, Behavioral Health, Oral Health and Non-Emergency Medical Transport with support of departments across CareOregon.
Responsible for monitoring network adequacy, developing strategy and measurable goals to optimize the provider network and enhance member access to services. This includes regular and routine reporting, Quest tool support for both Medicaid and Medicare standards.
In coordination with other departments, responsible for Provider Directory network & provider content oversight to ensure the Provider Directory meets regulatory requirements.
Manage and oversees any other required regulatory reporting and auditing functions that relate to network adequacy, access or management.
Collaborate with multiple departments to manage member PCP assignment to ensure assignment processes are working as designed, and to update assignment algorithms to match organizational priorities and objectives.
Responsible for development and oversight of “New Provider” processes and procedures in coordination with CCO’s, Behavioral Health and Oral Health- track network needs, applicants and resolutions.
Review network utilization and recommend changes that improve patient access and ensure network stability.
Provide support to Customer Experience and lines of business-related to network Language Access.
Develop a strategy and measurable goals for enhanced access and utilization of CareOregon network focused electronic and internet-based systems for operational improvements.
Act as resource for Provider Relations Specialists to resolve complex issues.
Responsible for maintaining content updates and provider communications related to the Provider Manual and coordinating updates with other internal departments.
Monitor daily operations including reporting and work queues for Provider Relations Specialists.
Take lead on department projects that improve patient access to care, provider network access and stability, and relationships with contracted providers.
Ensure that concerns and perspectives of provider network are represented at CareOregon.
Develop and implement provider education and training programs, communication plans and policies and procedures to improve provider satisfaction and meet operational and organizational business goals.
Interpret and clarify CareOregon provider policies and procedures for staff and provider education agendas.
Collaborate with Customer Experience on content, communication and resolution related to Provider Survey process.
Collaborate with Customer Experiece, Information Services (IS), Brand Marketing and Communication (BMC), and other departments to manage the content and structure of information available to members and providers in the Provider Directory.
Act as liaison with both internal departments such as Information Services for implementation of provider data system enhancements and external agencies such as DMAP, state agencies (AFS, SDSD, SCF) and community organizations.
Identify potential providers that may enhance network access and direct to the appropriate Provider Relations Specialist for recruitment.

Essential Department and Organizational Functions
Propose and implement process improvements
Meet deadlines for completion of daily, weekly, and month-end reporting
Maintain agreed upon work schedule
Demonstrate cooperation and teamwork
Provide cross-training on specific job responsibilities
Meet identified business goals that contribute to departmental goals

Management and Leadership

Train, supervise and evaluate performance of assigned staff.
Provide staff with the training, mentoring and resources necessary to carry out their work.
Ensure adherence to department and organizational standards, policies and procedures.
Ensure performance goals, expectations and standards are clearly understood by supervised staff.
Evaluate employees performance on an ongoing basis; take appropriate corrective action if needed.
Perform human resource functions in collaboration with Human Resources.

Knowledge, Skills and Abilities Required
Ability to work independently, organize, prioritize and manage multiple projects
Strong data analysis and computer skills required including word processing, spreadsheet and database
Excellent leadership abilities, including team building, staff development, and mentoring skills
Ability to work well under pressure in a complex and rapidly changing environment
Familiar with maintaining physician demographic databases
Ability to conduct group training sessions and to make presentations as needed to educate through formal and informal venues
Ability to create and update provider related policy and procedure
Knowledge of managed care and the Oregon Health Plan
Ability to understand and interpret contractual language
Knowledge of physician reimbursement methodologies, including the Resource-Based Relative Value Scale (RBRVS), capitation and ability to perform rate calculations
Familiarity with medical clinic operations
Demonstrated ability to develop and maintain professional relationships with providers, provider staff and other parties
Excellent customer service and interpersonal skills
Excellent written and verbal communication skills
Ability to problem-solve in an environment with diverse providers and provider groups
Knowledge of how to confidently diffuse situations and expertly resolve high exposure complaints
Skilled in negotiation and ability to build consensus
Strong statistical, analytical, problem solving, organizational and detail orientation skills
Possess a high degree of initiative and motivation
Ability to effectively collaborate and plan with coworkers and others

Physical Skills and Abilities Required

Lifting/Carrying up to 50 Pounds

Pushing/Pulling up to 0 Pounds

Pinching/Retrieving Small Objects

Crouching/Crawling

Reaching

Climbing Stairs

Repetitive Finger/Wrist/Elbow/

Shoulder/Neck Movement

1-3 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

Standing

Walking

Sitting

Bending

Seeing

Reading

Hearing

Speaking Clearly

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

Cognitive and Other Skills and Abilities

Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

Education and/or Experience

Required:

Minimum 4 years of experience in provider relations, managed care operations, medical clinic operations, or related health care organization
Minimum 1 year of supervisory or people leadership experience

Working Conditions

Environment: This position’s primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):
☒ Inside/office ☐ Clinics/health facilities ☐ Member homes

☐ Other_________________________________________

Travel: This position may include optional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.
Equipment: General office equipment
Hazards: n/a
Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

Position Description »