PM Compliance and Regulatory Initiatives

Manager of DSE Provider Network Operations will report directly to the Director for DSE Operational Solutions and leads a team of Network Quality Specialists and Network Operations Specialists that are responsible for managing core functions within DSE such as quality assurance auditing, contract implementation and creation and oversight of departmental policies and procedures. The Manager partners with business leaders to drive coordinating process improvements focused on increasing efficiency and reducing costs through the application of process improvement, quality tools and methodologies. This includes creating and managing process efficiencies that contribute to reduction in medical costs.

Duties//Responsibilities:

• Organizes and leads assigned process improvement projects using methods of team building, data gathering and analysis, process mapping, and problem solving
• Works with appropriate stakeholders to develop and document key processes (like what) within DSE
• Manages regular quality assurance audits on audit failures to ensure appropriate resolution has occurred (i.e. Access and Availability, compliance with documented policies and procedures)
• Partners with DSE teams (i.e. Ancillary, Hospital, Physicians, etc.)to coordinate implementation of new contract terms
• Understands underlying system set-up issues and offer recommendations (i.e. Contract loading, provider id set up)
• Establish and maintain excellent working relationships with corporate departments ((i.e. Provider Operations, Regulatory, Compliance, Reimbursement)
• Manages the the integrity of SharePoint and workflows associated with team deliverables
• Responsible for publishing report out of all work tracked assigned section of SharePoint
• Effectively communicate results to key stakeholders
• Creates presentations and presents as needed on issues // projects // audits conducted
• Tracks //Trends unresolved audit findings to reduce exposure to negative external audit findings
• Serves as the SME on process improvement
• Partners with the Directors//Managers in DSE to review quality assurance findings
• Conduct monthly presentations on the unit’s performance and results.
• Management of report requests and tracking of progress and completion dates
• Manages a team of professionals and responsible for supervision, coaching, performance management, and oversight.
• Ad hoc analysis related to explaining root cause drivers
• As determined by the Director of DSE Operational Solutions may be forward facing with providers as needed.
• Additional duties as assigned.

  Minimum Qualifications:

  • • High School Diploma
    • Managed Care operations; working with various business partners to facilitate resolution (Legal, Regulatory//Compliance, Quality)
    • Project planning small and large scale initiatives
    • Familiarity with implementing corrective action plans and recommending approaches on how to improve efficiency in process flows.
    • Great attention to detail
    • Creating presentations and presenting to management
    • Managing a team of direct reports
    • Critical thinking skills
    • MS Excel, Word, Power Point
      
      

      Hiring Range*:

      • Greater New York City Area (NY, NJ, CT residents): $81,100 - $117,470

      • All Other Locations (within approved locations): $71,600 - $106,505

        As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

        In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

        • The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.
        71600-106505