Pailin Group Executive Search
Manager of Contracting and Provider Relations
Job Locations US-GA-Atlanta
Req No 2019-9085
PHP (HMO SNP)
PHP is a Medicare Advantage Prescription Drug health plan specifically for Medicare beneficiaries who are living with HIV and reside in Fulton Counties. PHP is the first HIV-specific special needs health plan approved by the Centers for Medicare & Medicaid Services (CMS). This plan covers routine doctor and specialist office visits, emergency and urgent care, hospitalization, and more. It also includes a prescription drug benefit for no monthly premium
Essential Duties and Responsibilities for the Manager of Contracting and Provider Relations - GA:
Includes the following:
Identifies prospective providers and conducts pre-contractual evaluations.
Negotiates managed care network contracts with Medical Groups/IPAs, Ancillary and Facility contracts within plan guidelines, submits all outlier negotiations to the Director.
Is responsible for the development, maintenance and distribution of a comprehensive provider operations manual to contracted providers.
Develops and maintains strong, cost-effective and mutually supportive relationships with providers.
Monitors contract services and financial impact to ensure optimum results for MCO Network goals.
Assesses training and education needs of network providers and develops and delivers formal and informal educational presentations/orientations to participating providers and their staff. Assures the providers are educated in the MCO utilization, quality, billing, complaint and grievance, and other provider specific policies and procedures
Collaborates with Risk Adjustment Coordinator to assure providers are educated in the MCO requirements for medical record documentation and reimbursement processes.
Reviews contract templates on an annual and on an as needed basis to assure templates are up to date with state and federal requirements. Works with Director to update existing contracts to the current state and federal requirements.
Participates in strategic development of the contracted provider network with the Director of Contracting and Provider Relations as appropriate, including identification of expansion or contraction opportunities and needs.
In collaboration with the Compliance Officer, develops and implements a network provider site visit and compliance with contractual and regulatory requirements monitoring program.
Develops and implements an annual plan to ensure support to providers in an advisory role on a routine and timely basis.
Ensures Providers’ understanding of MCO products, services, contract details, and compliance with contractual requirements.
Ensures required provider education requirements are met on an annual basis, e.g., Model of Care, HIPAA, etc.
In collaboration with the Director of Contracting and Provider Relations, participation in Joint Operation Committee (JOC) meetings with MCO’s delegated vendors and subcontractor affiliations.
Ensures Provider Directories are accurate, current and accessible when needed by internal and external contacts and health plan members. Participates in developing appropriate internet access to all required Provider materials.
Assures that provider network changes are reported to contracting agencies within the contractual requirements.
Maintains Provider profiles to ensure a complete record of provider contract requirements and preferences are available to internal staff.
Participates in the development and distribution of provider satisfaction surveys.
In collaboration with the UM/CM Manager, participates in PCP and other provider site certification surveys and provider accreditation survey education.
Assists Credentialing Department in obtaining all necessary documentation for provider credentialing as needed.
Researches, analyzes and resolves complex problems dealing with Provider concerns. Follows Provider grievance procedure. Reports to the designated Committees and Director of Contracting and Provider Relations all provider related grievances or patterns of concern.
Assures required Provider reporting to MCO and regulators is accomplished in a timely manner
Travel within designated geographic areas to meet with current or prospective providers (e.g., PHP’s Service Area: Fulton, Cobb, Dekalb, Gwinnett, Douglas, Coweta, Fayette, & Clayton counties), to Southern Bureau & Managed Care offices in Fort Lauderdale and Los Angeles other counties where Healthcare Center sites are located.
Monitors prompt payment policies and procedures for compliance by providers and plan. Reports findings to the Quality Improvement Committee and other plan leaders as determined by the QI process.
Furnishes providers with reports or information concerning their practice patterns as directed by management.
Takes the lead in obtaining required provider information when provider network files are incomplete.
Recommends establishment of new or modified reporting methods and procedures to improve report content and completeness of information to and from providers.
To perform the job successfully, an individual should demonstrate the following competencies:
Interpersonal skills – focuses on solving conflict, not blaming; maintains confidentiality; listens to others without interrupting; keeps emotions under control; remains open to others’ ideas and tries new things; speaks clearly and persuasively in positive or negative situations; responds well to questions; demonstrates group presentation skills.
Leadership – displays passion and optimism; inspires respect and trust; mobilizes others to fulfill the vision; provides vision and inspiration to peers and subordinates; exhibits confidence in self and others; accepts feedback from others.
Managing people – includes staff in planning, decision-making, facilitating and process improvement; takes responsibility for subordinates’ activities; makes self-available to staff; provides regular performance feedback; develops subordinates’ skills and encourages growth; communicates changes effectively; builds commitment and overcomes resistance; prepares and supports those affected by change; monitors transition and evaluates results.
Responsibilities include assisting with interviewing, hiring, training, planning, assigning, directing work, performance appraisals, rewarding and disciplining employees and addressing complaints.
Well qualified professionals please forward current resume/CV, compensation requirements and interview availability to:
Debra Hartmann – Group Manager
Pailin Group Professional Search Consultants
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