Manage and implement network compliance programs to meet all regularory, accreditation and client standards in the assigned market – including managing the network portion around provider complaints and grievances. It will involve presenting results of our network compliance initiatives to internal leadership meetings and client committees. In addition, this role may also be assigned projects to develops and promotes a positive perception of assigned business unit by cultivating a customer- oriented, collegial relationship with providers and clients. Specifically, charged with conducting effective, clinically-substantive provider and client education and training programs for new network participants and new client implementations, as well as when provider performance issues warrant remedial focus. Leads in responding to and resolving provider issues; facilitates problem-solving with other internal operations stakeholders and client provider relations staff to achieve fair and timely resolution and positive outcomes with providers. Additionally, requires being proactive in communicating with high- impact providers in each market to ensure that the highest provider satisfaction levels are achieved and client appreciation is gained as a result.

• Collaborates with Compliance, Quality, Legal, Account Management and Operations teams on network requirements.
• Reviews and makes recommendations on Network polices processes and policies in place to meet all standards
• Provides orientation, training, education meetings, presentations, and focus groups to improve mutual understanding and enhance working partnerships with internal and external customers, including other departments, providers and client presentations.
• Oversees the high denial outreach/non-responder/high appeals initiative in all markets, initiating clinical education meetings with physicians.
• Establishes and maintains optimal communication channels with client provider relations and account management, promoting business unit`s ability to rapidly resolve provider issues.
• Collaborates with network management, corporate management, account management, operations, QI and other internal stakeholders through internal meetings and needs analysis to develop and implement proactive provider relations improvement strategies.
• Provides summary and problem specific feedback information, analysis, action recommendations to service center senior management and relevant functional units regarding provider problems, issues, and general concerns impacting working relationships and company image.
• Manages provider relation`s department day to day activities and may manage staff.
• Directs, monitors, trends, routine and long-standing provider complaints, claims, contracting, credentialing and other problems requiring regional service center follow-up and resolution.
• Facilitates immediate resolution of red-flag provider issues that are client, community, legal, or contractual threats with internal personnel as needed.
• Routinely monitors provider performance to target and perform remedial training sessions based upon area of need (e.g., authorization processes, claims submissions, etc.

Other Job Requirements

Responsibilities

10+ years of experience in a Provider Relations role for a managed care plan.
2+ years’ experience or demonstrated knowledge of network regulatory requirements and network management to those requirments.
Project Management experience preferred.
Solid knowledge of health plan operations required.

General Job Information

Title

Senior Provider Relations Manager- Louisiana ECSS

Grade

26

Work Experience - Required

Network, Provider Relations

Work Experience - Preferred

Education - Required

Bachelor's

Education - Preferred

Master's

License and Certifications - Required

License and Certifications - Preferred

Salary Range

Salary Minimum:

$70,715

Salary Maximum:

$113,145

This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.

This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.

Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.