Manager Provider Network Management bei None

Role Overview: The Manager of Provider Network Management oversees the day-to-day operations of the Network Management department, including staff supervision, provider contracting, recruitment, and compliance. This role ensures the provider network meets regulatory standards and supports the healthcare needs of plan members. The manager also leads initiatives to improve provider satisfaction, streamline processes, and enhance electronic strategies for claims and auto-adjudication.

Work Arrangement:

• Hybrid -This role requires the associate to be onsite at the Southfield, Michigan (MI) office at least three days per week, including mandatory in-office days on Tuesdays and Wednesdays.

Responsibilities:

Network Development & Contracting

• Lead the development and management of hospital and physician networks across current and expansion markets.
• Recruit providers and negotiate contracts that align with company standards and regulatory requirements.
• Ensure provider contracts comply with pricing methodologies, Medicaid fee schedules, and internal payment systems.
• Resolve complex contracting issues and ensure non-standard terms are properly communicated and approved.
• Oversee the accuracy, timeliness, and compliance of all provider contracts.
• Implement electronic strategies to enhance claims submission and auto-adjudication processes.

Provider Recruitment, Retention, & Relations

• Ensure network adequacy in accordance with state and accrediting agency standards.
• Develop and execute strategic recruitment plans based on geographic and specialty needs.
• Collaborate with internal departments to retain providers at risk of termination.
• Modify and expand the network to support new products, clients, and service areas.
• Serve as a liaison between the health plan and provider community.
• Oversee provider education, training, and communication initiatives.
• Resolve provider complaints promptly to minimize network disruption.
• Conduct annual provider satisfaction surveys and lead improvement efforts based on feedback.

Quality & Compliance

• Monitor provider compliance with claims policies and recommend corrective actions.
• Support system upgrades, regulatory directives, and corporate initiatives.
• Track and analyze capitation, provider rosters, and Rural Health Clinic (RHC)/ Federally Qualified Health Center (FQHC) reports to address outliers.
• Collaborate with the Quality Management team on initiatives such as Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Commission (URAC).
• Participate in internal and external committees as needed.

Leadership & Administration

• Manage departmental staffing, performance evaluations, and professional development.
• Foster a collaborative and growth-oriented team environment.
• Guide staff in using data and analytical tools to improve quality and efficiency.
• Communicate policy and procedural updates effectively across the team.
• Recommend and implement operational improvements to optimize resource utilization.

Education & Experience:

• A bachelor’s degree in Business, Healthcare Administration, or a related field is required.
• Minimum 5 years of experience in managed care or healthcare setting.
• 3 to 5 years of provider contracting and reimbursement experience.
• 3 or more years of supervisory or leadership experience, preferably in managed care.

Licensure:

• Valid driver’s license and current auto insurance

Skills & Abilities:

• Strong organizational, analytical, and communication skills
• Ability to manage conflict, resolve issues, and lead teams effectively