Overview

This opportunity is open to remote applicants in the United States, with the exception of the following states:

Washington, Wyoming, North Dakota, and Ohio. Must be able to work mountain time.

This role exists to ensure the integrity of provider contracting, development of new networks and new reimbursement methodologies and contracting strategies. Supports the Director of Provider Reimbursement in determining fair and equitable provider reimbursement rates. This role provides leadership to the department staff whose focus is recruiting providers, contracting and re-contracting with providers and implementing contracts. Acts as a key resource in developing provider payment systems that will move the Health Plan in a direction that reduces expenses while maintaining a quality network. The manager provides direction and support for ensuring successful execution of contract compliance with PHP policy as well as compliance with applicable Medicare, Medicaid and other third party guidelines. Manager is responsible for identifying issues, resolving and coordinating resolution of complex disputes or issues. Manages and coordinates assignments and work productivity of supervised staff. Executes PHP s network development strategies and initiatives. Ensures that productivity and quality standards are maintained. Provides leadership and assistance to Supervisor, Provider Network Development, Network Contract Managers and Contract Administrators

Type of Opportunity: Full Time FTE: 1.000000 Exempt: Yes Work Schedule: Days

Qualifications

Bachelors degree in business administration, or related health care field or three to five years progressive experience in provider relations, provider contracting, claims processing, correct coding, and customer service in a managed care organization. 6 years of additional experience can be substituted in lieu of degree 4 years of application specific experience. A minimum of two years management experience. Requires effective coaching, counseling, and conflict management skills. Must be able to work collaboratively with other employees and the ability to multi-task. Demonstrated ability to sustain quality standards. Demonstrated ability to communicate in verbal and written form with peers, subordinates and the public, including physicians, physician office staff and staff. Ability to handle fluctuating workloads, conflicting priorities, and concurrent activities.

Responsibilities

*Manages and oversees all aspects of Provider Network Development as is necessary to accomplish: a) Marketing an attractive managed care network throughout the State of New Mexico. b) Ensuring access to quality health care for health plan beneficiaries. c) Meeting enterprise goals of improving affordability and fiscal sustainability. d) Meeting health plan standards regarding operational administration and reimbursement automation.*Negotiates and resolves complex provider contracts and reimbursement issues. Researches problems and negotiates with internal/external partners/customers to resolve highly complex and/or escalated and sensitive issues. Identifies necessity for additional escalation and communicates issues effectively to senior leadership.*Develops new provider networks, reimbursement contract terms and contract strategies and conditions.*Evaluates, reviews and approves proposed payment methodologies as requested by providers.*Develops and manages new and existing provider networks in support of PHP strategies while exercising discretion, as appropriate, with sensitive contractual matters, while maintaining confidentiality.*Ensures team members perform tasks in accordance with established department and organization policies and standards.*Ensures team is focused on appropriate goals and removes barriers to success.*Acts as a point of contact, liaison and escalation for all team solution delivery matters.*Ensures that performance standards are being maintained by performing ongoing monitoring and audits of processes and workflows. *Provides counsel and feedback to team members regarding audit and performance results*Recruits and retains staff and coordinates training with the Network Instructional Designer for new and existing team members.*Effectively works with peers, team members, and other key stakeholders leading or participating in process improvement; acting as a catalyst for change. *Conducts periodic team meetings to communicate strategy and modifications in policies and procedures and help develop interpersonal relationships/teamwork.*Acts as a role model and mentors others to deliver customer service that meets/exceeds provider expectations, resulting in an exceptional provider experience.*Works effectively with cross-functional departments and external customers.*Motivates and encourages staff through positive communication and feedback.*Regional travel as required to meet with providers for purposes of recruitment, re-contracting, provider education, and/or attendance for any provider related functions

Benefits

We offer more than the standard benefits!

Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!

Learn more about our employee benefits:

https://www.phs.org/careers/why-work-with-us/benefits Why work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.

Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.

About Presbyterian Healthcare Services

Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

About Our Regional Delivery System

Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.

We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico

New Mexico continues to grow steadily in population and features a low cost-of living.

Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.

New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Maximum Offer