Manager, Provider Relations Complaint Services/Response

We’re looking for a Manager of Provider Complaint Services & Response, someone who’s ready to grow with our company. In this position you will plan, direct and maintain strategies that ensure harmonious relationships are established and maintained with physicians and other providers and efficient, effective care is delivered to membership. Educate providers through in-service programs that review policies and procedures physicians are obligated to adhere to, discuss physician feedback as necessary and promote continuing education classes as well as other educational programs that support the goals and objectives of the health plan.

Think you’ve got what it takes?

Job Duties & Responsibilities
•    Supervises staff responsible for support of regional territories inclusive of provider education, communication, claim research and survey completion. Acts as an internal and external liaison to resolve managed care issues, contract implementation, contract interpretation, and maintain positive relationships with providers through understanding territory demographics and health service needs.
•    Conducts claims payment assessments in conjunction with staff to identify and address issues with over or underpayment, elements requiring configuration change and issues to address in communication campaigns with providers and develops plan for claim or requirement-based communication and action including interventions to influence medical loss ratio. Produces trended correlation of medical use to facilities and assigned delegated provider groups. Evaluates provider use/billing for patterns demonstrating best practice.
•    Represents Provider Relations at various meetings, both internal and external, which includes the IDS, stakeholder meetings, HHSC and TDI.
•    Assures compliance with all regulatory and accreditation rules and regulations as they relate to network accessibility, professional services, and coordinate responses to Texas Health and Human Services provider complaints with claims director, business systems assistant director and contracts director.
•    Serves as Team Leader for various special projects as assigned by the Director related to strategic initiatives in regional territories. Extensive analytical responsibility included in assessment and reassessment of activity within network that may influence health delivery, membership growth and/or access to care.
•    Ensures compliance with State and Federal guidelines in communications to providers including provider manuals, online tools, education materials and presentations.

Skills & Requirements
•    High School Diploma or GED required
•    8 years health care or managed care experience required
•    A bachelor’s degree may be substituted for four (4) years of experience, and an associate’s degree may be substituted for two (2) years of experience.)

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