Summary: Under the direction of the CEO, this position is responsible for continued development of national PPO network, PPO rate negotiations, credentialing system, orientation of providers, and provider-related quality assurance. Oversees departmental staff and operations.
Under the direction of the CEO, and in cooperation with all divisions as deemed appropriate:
- Oversee development, expansion, and maintenance of PPO network coverage, to include new provider identification, solicitation, and negotiation, as well as client/case-specific provider affiliations. Ensure adherence to established provider fee schedules. Recommend changes as appropriate. Supervise inpatient/outpatient rate negotiations and approval of inpatient contracts.
- Ensure accurate and complete process of initial and ongoing credentialing of PPO providers, in accordance with established policies and national accreditation standards. Maintain current, accurate and confidential provider files and PPO listings. Assist in URAC accreditation process/preparation as directed.
- Administer BHS provider orientations, to include individual and regional provider training sessions. Arrange and provide for clinical training/continuing education for providers, as directed. Reimplement the production of a provider newsletter on a regular basis. Handle provider complaints and ensure the retention of all desired PPO providers.
- Ensure competency and productivity of division staff. Ensure adequate network development efforts are being employed at all times. Ensure adequate network expansion in advance of new client contracts. Work closely with Director, Provider Relations on issues relating to staff hiring and supervision.
- Ensure the on-going development and maintenance of the computerized provider management system adequate for tracking utilization of resources, credentialing status and claims processing. Ensure adequate provider QA monitoring, to include onsite inspections, and ongoing performance and credentialing reviews, consistent with policies.
- Provider Relations Division serves in direct support role to the Clinical Division. Assist Clinical Division as directed in client/case-specific provider hook-ups and problem-solving. Assist Clinical Division as directed in arranging for client EAP supervisor and employee training in-services.
- Assist Clinical Division, BHS ASSIST Division, Behavioral Comp Management, Finance and Corp Relations/Marketing Divisions as requested in support services related to specific or potential client contracts. Assist in preparation of proposals as requested, i.e., network analyses. Assist in new product network development as directed/required.
- Maintain corporate, departmental and quality assurance policies and procedures. Recommend new policies/procedures as deemed appropriate. Recommend revisions to provider contract forms as appropriate.
- Participate in on-going marketing and provider relations efforts, as directed. Participate in special projects, on-going research and public relations efforts as appropriate. Maintain information on competition, provider rates by region or city, national statistics and relevant changes in the field. Make recommendations on product line enhancements. Prepare reports as requested.
- Perform other related duties as directed or deemed appropriate. Attend meetings as requested. Advise CEO on developments in the field.
- Bachelors in related field. Masters degree preferable;
- Five years provider relations experience required, preferably in PPO or similar setting;
- Experience in managed care/healthcare benefits environment;
- Some experience/involvement in mental health field preferred;
- Familiarity with care management/util. review functions;
- Proficiency with computerized applications (Word, Access, Excel);
- Experience in services to business & industry;
- Experience with contractual terms & rate negotiations;
- Excellent communication skills (written and oral) and organizational skills;
- Experience in group presentations/speaking preferable.