Provider Networks & Contracting Manager - Aspire Health Plan (Onsite)
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- CHOMP has been voted the Best Place to Work in Monterey County for 10 straight years
- Excellent Pay and Generous Benefits including a Pension and Continuing Education Reimbursement
- Excellent Team Oriented Culture
- Free Gym for Employees
Purpose of Position
The Provider Networks & Contracting Manager is responsible for the management and maintenance of Aspire Health Plan’s internal and delegated provider networks in a manner that is consistent with NCQA standards, CMS and DMHC requirements and Aspire Health Plan Policies and Procedures. This position is responsible for the contracting, credentialing, and oversight of all contracted providers, facilities, and organizations in all applicable provider networks. The Provider Networks & Contracting Manager acts as the head of the Provider Networks & Contracting Department and is responsible for the growth and oversight of department staff. The Provider Networks & Contracting Manager will act as an internal resource for provider-related needs or concerns.
* Acts as the health plan’s lead internal resource for all provider engagement, contracting, credentialing and oversight activities.
* Responsible for ensuring that all contracted provider networks are managed according to CMS and DMHC requirements (as applicable), as well as meeting or exceeding NCQA standards.
* Manages the Provider Networks & Contracting Department and any department staff hired into the department, promoting collaboration and communication between applicable Plans and the related provider networks.
* Initiates, grows, and manages relationships with our internal and delegated provider networks, providers and contracted facilities and acts as a resource for all departments. Some examples of this would be:
o Leveraging provider relationships to encourage participation in health plan initiatives that support the goals and objectives of the integrated health delivery system.
o Assist Appeals & Grievances Department by leveraging provider relationships to ensure timely response and, if necessary, to enforce the terms of the provider’s contract.
o Assist the Sales team with member requests for new provider contracts or adding a member to a closed panel.
* Project management for any new initiatives involving contracted providers; works to garner the support of the provider network(s) to accomplish Plan goals.
* Participation in all workgroups related to contracted Providers, Networks, Facilities, or Organizations.
* Writes all Letters of Agreement/Single Case Agreements to minimize plan risk when an enrollee engages the services of an out of network provider or facility.
* Works with Aspire Compliance Officer to ensure departmental and provider compliance with federal, state, and local regulations. Namely:
o Manages the process by which health providers are checked against various federal and state sanction lists that prohibit them from accepting federal reimbursement, then reporting these results to the Compliance Officer and Medicare Advantage Compliance Committee (MACC);
o Reports the results of the selection and evaluation of health care professionals that conform with federal and state credentialing requirements and provider anti-discrimination policies; and
o Partners with the Compliance Officer to organize and conduct state or federally required site visits (as applicable) to evaluate the site’s accessibility, appearance, and adequacy of equipment, using standards developed by Aspire.
* Works with the Director of Utilization Management to analyze UM data and monitor for any specific trends to be addressed at the Provider or committee levels.
* Prepares for state and federal audits and surveys, responding to auditor’s inquiries and preparing responses to auditor findings in collaboration with all departmental leaders.
* Facilitates the Aspire Credentials Committee, key responsibilities include:
o Ensuring that all contracted Provider, Facilities and Organizations that provide billable services to enrollees are credentialed according to CMS and DMHC requirements (as applicable), NCQA Standards and the Policies and Procedures of each Plan before a contract is signed and no less frequently than every 36 months thereafter.
o Provide continuous monthly monitoring of all contracted Facilities and Organizational providers, bringing any sanctions or issues of concern to the committee for review and discussion.
* Work closely with the Appeals and Grievances department to track quality of care or safety issues, bringing any such concerns to the Committee for review. Under the direction of the MBIPA President and Plan Medical Director, facilitates all MBIPA Board activities, preparation of all committee and Board meeting documentation, as well as credentialing data for review by Board. Attends MBIPA Board meetings. Creates and revises policies, procedures, and workflows to ensure the management of all provider networks in accordance with applicable laws and contract requirements, while meeting or exceeding NCQA Standards.
* Other duties as assigned.
* Leadership: Act and participate in all company activities in a manner that inspires confidence, always striving for personal and departmental improvement and excellence.
* Accountability and Dependability: Assumes responsibility for accomplishing duties in an effective and timely manner.
* Integrity: Consistently honors commitments and takes responsibility for actions and words.
* Software and Computer Skills: Highly skilled in the use of Microsoft Office Suite. Highly skilled at using the Internet. Able to quickly learn new software as technology changes. Learns effectively with computer-based and/or online training.
* Flexibility: Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.
* Inclusiveness: The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.
* Specific knowledge, experience, and demonstrated ability in areas of credentialing, management, health systems and Medicare.
* Expert level knowledge of credentialing in accordance with NCQA standards.
* Thorough understanding of provider contracts and healthcare reimbursement.
* Ability to actively participate in and support the goals, vision, and overall direction of a system designed to care for a population of patients across the care continuum.
* Ability to communicate effectively and professionally, both verbally and in writing.
* Ability to provide excellent service to all clients, providers, stakeholders and vendors.
* Ability to summarize information clearly, thoroughly, and quickly in writing.
* Detail oriented with excellent organizational skills.
* Exceptional diplomacy skills to effectively resolve issues under sometimes tense and stressful circumstances.
* Readily adaptable to the changing needs of the business; able to manage multiple priorities; tolerance for ambiguity.
* Ability to use sound judgement, identify next steps to be taken, and develop appropriate solutions.
* Ability to work quickly and accurately and balance work load against shifting priorities and do so while maintaining a positive outlook and approach.
* Solid Medical Terminology and healthcare industry knowledge.
Skills and Education
* Bachelor's degree in a relevant subject
* Minimum of 5 years’ experience in contracting and credentialing, 3 years of Management experience and at minimum 2 years’ experience working with Medicare, preferably in a managed care environment.
Assigned Work Hours: