78 Humana Provider Network Manager Jobs Hiring Near You

FLSA Status: Exempt
Department: Provider Network Operations
Reports To: Director, Provider Network Operations

GENERAL DESCRIPTION OF POSITION
The Manager, Provider Network Operations is responsible for providing day-to-day management and leadership of the Provider Network Operations team responsible for establishing and maintaining excellent relationships with SCFHP's provider network. This involves the development and execution of strategies related to communication, outreach, training, education, and service to the SCFHP provider network. The Manager designs and implements programs to build and nurture positive relationships with providers, staff and leadership of contracted health plans, physicians, hospitals, ancillary providers, IPAs, various types of health care facilities, and non-traditional medical providers. Responsibilities include conducting outreach to build relationships, conducting initial and subsequent provider orientations and ongoing training, troubleshooting concerns related to the provider's contract or operational issues, and implementing ongoing quality and service improvement initiatives in support of a positive member and provider experience. In addition to the externally, provider facing interactions, the Manager works collaboratively with the Director, Provider Network Operations, representing the department at management and cross-functional meetings and interfacing with other departments as necessary.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.

1. Develop and maintain in depth market knowledge regarding the provider community in Santa Clara County.
2. Develop comprehensive training and resource materials related to SCFHP processes and procedures. This includes drafting and maintaining the SCFHP Provider Manual, website and provider portal content, providernewsletters, bulletins, tool kits, training materials, presentations, , and other planned and ad hoc provider communications.
3. Create effective strategies for conducting provider outreach to provide timely information to the SCFHP provider network and to receive timely feedback from the network. Assure timely and appropriate responses to provider inquiries.
4. Develop and conduct internal training across departments to assure appropriate knowledge and tools exist throughout the organization for servicing providers and understanding handoffs between departments.
5. Represent the department at SCFHP committee meetings and workgroups. Act as a subject matter expert for cross-functional activities. Be the voice of the provider community at SCFHP, communicating the needs of the provider network as they relate to administrative processes, policies and performance.
6. Manage the Physician Advisory Council, developing relationships with participants, organizing meetings and agendas, in compliance with the Brown Act. Keep topics engaging and relevant to current health plan priorities including SCFHP's Quality Improvement Health Equity Program, market trends and the regulatory environment.
7. Oversee the provider network associate's responsible for Joint Operations Committee meetings with providers, ensuring the agenda topics are timely, relevant, engaging, and actions are documented and receive appropriate follow through.
8. Hire, manage and develop the provider network associate team to ensure effective communication strategies, including timely, documented efforts related to education of new and existing providers, questions from providers, interventions addressing concerns regarding quality of service impacting health plan members, and action plans that pertain to specific initiatives with the SCFHP provider network.
9. Coordinate with Provider Network Operations management to create seamless hand offs related to onboarding, credentialing and recredentialing of providers, contract implementation, Service Level Agreement (SLA) monitoring, and ensuring accurate set up and configuration in SCFHP systems.
10. Communicate clearly and concisely with providers at all levels, including administration, the provider office staff and relevant vendors; convey information to internal departments and organizational leadership when appropriate.
11. Collaborate and work closely with the Manager, Provider Practice Transformation to conduct studies on operations, workflows, and fact gathering sessions with providers and transformation consultants to document, quantify, and specify quality improvement efforts. Work with providers and internal/external stakeholders to identify gaps and solutions to closing gaps between current and desired results.
12. Manage compliance with applicable regulatory and reporting requirements; monitor new requirements and update required program documents accordingly.
13. Identify issues, trends, and opportunities to improve efficiency and/or quality, or to better collaborate with departments and providers.
14. Identify, research, and resolve program issues and escalate critical issues, problems, and delays to management and executive leadership, as needed.
15. Participate in the implementation of new member benefits, including developing work plans to develop new provider relationships, as applicable.
16. Conduct Provider Satisfaction Surveys, evaluate results and conclusions, and establish work plans for continuous improvement.
17. Perform other related duties as required or assigned.

SUPERVISORY/MANAGEMENT RESPONSBILITIES

Carries out supervisory/management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include:

1. Recruiting, interviewing, hiring, and training.
2. Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives.
3. Effectively assimilate, train and mentor staff and (when appropriate), cross train existing staff and initiate retraining. Coach to help increase skills, knowledge and (if applicable) improve performance.
4. Set goals and plan, assign, and direct work consistent with said goals. Respond to employees' needs, ensure they have the necessary resources to do their work.
5. Contribute to achieving organizational objectives in line with the organization's values by managing all aspects of performance management, including appraising performance, giving timely effective feedback, providing recognition, addressing complaints, resolving issues, and providing progressive discipline. Monitor work schedules and time off requests to ensure that adequate coverage is available for internal staff during regular business work hours.

REQUIREMENTS - Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. Bachelor's Degree in Business, Healthcare Administration, or a related field, or equivalent experience, training or coursework. (R)
2. Minimum six years of experience in a health care, managed care setting, provider organization or health policy organization requiring routine interaction with internal and external stakeholders and program management responsibilities. (R)
3. Demonstrated achievement and progressive responsibilities in the area of provider network management. (R)
4. Minimum three years direct supervisory/management experience. (R)
5. Ability to establish and maintain effective internal and external working relationships to organize and lead cross-functional teams. (R)
6. Experience developing training materials. (R)
7. Ability to create and deliver effective presentations to diverse groups. (R)
8. Ability to consistently meet compliance accuracy and timeline requirements by achieving regulatory standards. (R)
9. Ability to organize, plan, direct and manage medium to large scale, complex, cross-functional, multi-departmental projects and/or programs to completion with minimal supervision; able to manage multiple concurrent initiatives and effectively prioritize in a dynamic environment. (R)
10. The ability to track, gather and analyze large data sets and organize/write reports. (R)
11. Strong project management experience. (R)
12. Knowledge and experience with program evaluation. (R)
13. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers, and outside entities over the telephone, in person or in writing. (R)
14. Strong writing skills and demonstrated proficiency in developing content related to provider manuals, training materials and web content. (R)
15. Strong understanding of NCQA, HEDIS and government requirements. (R)
16. Proficient in adapting to changing situations and efficiently alternating focus between tasks to support department operations as dictated by business needs. (R)
17. Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word and Excel. (R)
18. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
19. Ability to maintain confidentiality. (R)
20. Ability to comply with all SCFHP policies and procedures. (R)
21. Ability to perform the job safely with respect to others, to property and to individual safety. (R)
22. Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from off-site meetings or events, or the ability to use other means of transportation to attend off-site meetings or events. (R)

WORKING CONDITIONS
Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 15 pounds; (R)
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

ENVIRONMENTAL CONDITIONS
General office conditions. May be exposed to moderate noise levels.