Provider Relations Network Manager

We are looking to hire a Provider Relations Network Manager to help support our Provider Relations Network Management team in Southern California in Orange County and surrounding areas.

The Provider Relations Network Manager is responsible for general management of the provider network as assigned by the Director of Network Management as well as for supporting the Network Management Department in meeting the overall network growth and development goals.

Essential Duties and Responsibilities include the following:

• Responsible for working collaboratively with the Director of Network Management and Medical Management team to ensure network growth and development initiatives are being met and are networks are operating within budgets.
• Responsible for the preparation and negotiation of provider contractual agreements during Primary Care, Specialty and Ancillary recruitment projects.
• Responsible for New Provider and Staff Orientations and continued education of existing providers to ensure company programs and initiatives (i.e. P4P, HCC, Vital Care, Encounters, etc.) and process is being effectively communicated and followed by the provider network. Also, to ensure provider is effectively utilizing company tools (i.e. REA, iCode, etc.) available to them.
• Responsible for the oversight of their assigned networks to ensure network provider deficiencies are being met and working closely with their assigned
• Network Support staff and Medical Management counterparts to ensure network needs/changes are being effectively addressed and communicated both internally and externally.
• Maintaining and updating the appropriate databases and department tools with current information.
• Responsible for the coordination, receipt, and review and processing of all provider contracts, credentialing, and provider correspondence to ensure the department has obtained proper signatures and documentation to effectively process newly recruited or existing providers.
• Responsible for timely and accurate completion of PACF’s related to incoming documentation received from providers regarding changes to their demographic information in the credentialing and provider network databases.
• Responsible for submitting provider profiles to the Health Plans, conducting required follow-up to ensure Primary Care Physicians are active in health plan databases and obtaining health plan assigned provider identification numbers in affiliation with Regal. Also, responsible to ensure terminated PCP’s are effectively terminated and enrollment retention efforts are followed.
• Responsible for the review of Health Plan Directories for assigned network/s as well as communication of adds/terminations/changes to the health plan.
• Assist with the resolution of provider grievances and appeals in accordance with contractual requirements and corporate policy.
• Daily interaction with regional providers and at minimum quarterly visits to PCP and Specialist offices unless visit is warranted at earlier.
• Ensure contract compliance and adherence to DMHC, DHS, CMS and other regulatory agencies as required by company policy and contracting HMOs.
• Internal network liaison for Database, Claims, Customer Service, Medical Management, and Quality Management Departments.
• Perform on-site visits (as required) to physicians, physician groups, hospitals and ancillary providers.
• Facilitate the quarterly Joint Operations Meetings with contracted providers and office staff.
• Oversight of database maintenance and accuracy through use of audits.
• Ensure accurate and timely data reporting requirements are being met including eligibility and capitation reports, risk sharing, claims timeliness, pharmacy utilization, bed day’s utilization, encounter data and audit compliance.
• Know and follow the Employee Handbook policies and procedures.
• Maintain patient confidentiality so that HIPPAA compliance is observed at all times.
• Other duties directed by management.

Distribution of work:

• Daily production will vary from day to day. All assigned work must be completed by the end of business day in order to maintain turnaround time compliance.

Special Projects:

• Assist with any special projects.

Education and/or Experience:

• Minimum of 3 years relevant work experience in Network Management, Contracting or Provider Relations in a managed care setting, health plan or large medical group administration.
• Knowledge of contracting principles/tools.
• Excellent verbal and written communication skills.
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
• Must be able to travel within service area 70-80% of the time and have valid driver’s license and insurance.

The pay range for this position at commencement of employment is expected to be $70,304/year however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Education and/or Experience:

• Minimum of 3 years relevant work experience in Network Management, Contracting or Provider Relations in a managed care setting, health plan or large medical group administration.
• Knowledge of contracting principles/tools.
• Excellent verbal and written communication skills.
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
• Must be able to travel within service area 70-80% of the time and have valid driver’s license and insurance.