Manager, Provider Servicing

Position Summary:

The Provider Operations supervisor will lead a team that is accountable for growing positive, long-term relationships with network providers in order to foster positive provider experiences, accurate and timely provider claims submissions, and high-quality care delivery among network providers leading to improved financial and quality performance. They will oversee a team of direct and reports responsible for provider relations and training, claims education, provider engagement and practice transformation. The Supervisor, Provider Operations will be responsible for setting strategic direction for Community Care Plan provider operations department ensuring that all provider services functions meet contractual requirements and ensuring state reports are completed timely and accurately. The Supervisor, Provider Operations requires an in-depth understanding of how organizational capabilities are interrelated across the departments. This is a dynamic role requiring strong leadership experience, critical thinking/problem solving skills, and a strategic mindset.

This position is instrumental in assisting the Provider Operations Department Director in achieving short and long term operational/strategic business goals/ by developing, enhancing, and maintaining operational processes. They will also develop, in conjunction with the Director, and implement effective/strategic business solutions through research and analysis of data and business processes.

Essential Duties and Responsibilities:

• Provides leadership, development, and oversight to the Provider Operations Sr. Representatives and Provider Operations Representatives.

• Sets strategic direction for and oversee key business functions, including provider relations and training, claims analysis and education, provider quality and value-based payment performance in accordance with NCQA standards.

• Develops and updates operational policies and procedures to align with the provider servicing model and executes on strategic initiatives for all lines of business.

• Develops and updates provider educational materials including but not limited to provider manuals, orientation materials and training documents.

• Enables the development and growth of positive, long-term relationships with physicians, key provider group, non-hospital facilities, Rural Health Clinics, behavioral health providers, FQHCs and other healthcare systems to foster provider retention and improve financial and quality performance within the provider network. Develops strategies to align contracted provider groups with company initiatives, goals (revenue and expense) and quality outcomes.

• Increases provider satisfaction through staff engagement and provider education initiatives based on input obtained from annual provider satisfaction survey.

• Provides oversight and governance of provider audits, provider surveys, provider servicing and relations, and provider feedback.

• Regularly reviews reports provider complaints data and trends, claims denials/reprocessing data and trends, provider training and communications, and provider performance data to monitor team performance and guide strategic improvements where needed. Understands cost drivers, performs competitive benchmarking, and constantly works to improve value delivery to the organization.

• Represents the provider services team at meetings and regularly meets with key provider groups.

• Assists with ensuring that providers are compliant with NCQA requirements, for example availability and access to care standards.

• Ensures team's compliance with Managed Care contractual requirements for Provider Operations such as claims dispute resolution within specified timeframes.

• Sets and monitors team key performance indicators (KPIs) and strategic goals.

• Works closely with the Provider Operations Director and Manager to plan and execute upon regular and ad hoc provider communications and strategy for provider training and education.

• Provides tactical operations support to assigned groups including contracting, data integrity, communications, and relationship management.

• Conducts regular performance evaluation of employees and provides ongoing feedback and coaching as necessary to achieve service, quality, and production goals.

• Identifies and supports professional development for their team to drive exceptional associate engagement and performance.

• Responsible for managing several projects at any given time.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by management.

Skills and Abilities:

• Familiar with a variety of concepts-risk, capitation and fee-for-service payment methodology, industry practices and health care procedures.

• Analyzing, reviewing, and presenting information for operational and business planning.

• Verbal and written communication skills.

• Ability to speak clearly and concisely.

• Time management skills.

• Proficiency in analyzing, understanding, and communicating financial trends.

• Ability to manage priorities in a fast-paced environment.

• Presentation, Organizational and Prioritization skills.

• Ability to multi-task and meet deadlines.

• Problem solving skills.

• Maintain a professional image and attitude.

• Exceptional customer service skills.

• Strong public speaking and presentation skills.

• Able to prioritize and organize multiple tasks.

• Ability to make decisions in the absence of detailed instructions and work independently or in a team environment.

Work Schedule:

As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week.

*The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.

Qualifications

• Must reside in South Florida

• Must be able to travel in Florida and commute to Sunrise office twice weekly

• Bachelor's degree (B.A/B.S.) or 5-7 years related experience

• Previous supervisory experience

• Experience working for or with key provider types (primary care, FQHCs, hospitals, nursing facilities, and/or HCBS and LTSS providers).

• Minimum of 3 years of managed care experience in Provider Services

• Experience with data analysis, understanding, communicating, and reporting on operational trends and gaps.

• Knowledge of Medicaid regulatory requirements.

• Knowledge of Microsoft office suite

• Must possess a valid Driver's License