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Provider Contracts Manager

Western Growers Family of Companies

This is a Full-time position in Phoenix, AZ posted May 1, 2021.

Provider Operations Irvine, California Fresno, California Sacramento, California Phoenix, Arizona Imperial, California Oxnard, California Salinas, California Yuma, Arizona

The Provider Network Manager is accountable for the management of the contracting and network management activities to ensure superior access to the highest quality, cost-effective Providers of healthcare services for our Members and competitiveness in the marketplace for the company.

This includes network development, sourcing of Providers, contract negotiation, and measuring, monitoring and reporting on the status of contract agreements and relationships.

In addition, this position will analyze and maintain internal cost containment programs for Western Growers Assurance Trust & Pinnacle Claims Management Inc.

This position reports to the Manager of Provider Operations.

Qualifications
Bachelor’s degree in Business, Healthcare or similar field preferred and five years of experience in Provider contract components, fee schedule determination, credentialing, claims processing and pricing, preferred.

Exceptional in-depth healthcare/insurance knowledge for medical and dental Provider relations and operations; network development, network contracting, account management, Provider services, Provider contracting.

Comprehensive k nowledge of Provider fee schedule developments in Diagnosis Related Group (DRG), current procedural terminology (CPT), resource-based relative value scale RBRVS and healthcare common procedure system HCPCS .

Advanced computer software skills in word processing, spreadsheet and database management .

Possess a high attention to detail with strong analytical and mathematical skills .

Effective project management skills and the ability to manage multiple projects at one time .

Motivated self-starter with the ability to prioritize, multitask, work under pressure and tight deadlines, work independently and effective problem solver .

Possess strong communication and interpersonal skills .

Verifiable, clean DMV r ecord and the ability to travel to various locations throughout the U.S.

(mainly California and Arizona) up to 30% of the time .

Duties And Responsibilities

Network Development
Develop and maintain a Provider network comprised of physicians, hospitals and ancillary groups that is competitive and provides broad healthcare access to patients.

Negotiate and build a stable Provider network that achieves objectives for unit cost performance & trend management and produces an affordable & predictable healthcare insurance product.

Evaluate and negotiate contracts with healthcare Providers in compliance with contract templates, reimbursement structure standards, and other key process controls.

Coordinate and implement the installation of new Provider contracts with each Provider office and their staff, including written procedures for billing, eligibility verification and other contractual requirements.

Ensure regulatory and statutory compliance of Provider contracts and execute on remediation efforts.

Relationship Building
Establish and maintain relationships with healthcare Providers and ensure the network composition includes an appropriate distribution of Provider specialties.

Collaborate with various cross-functional departments within the organization, such as Installation, Claims, Sales, Underwriting, Utilization Management, Account Managers, etc.

to ensure the timely & accurate implementation of new contracts.

Assist in resolving elevated and complex Provider complaints and/or escalated issues with internal/external partners/customers.

Serve as a representative of Western Growers Assurance Trust/Pinnacle Claims Management Inc.

, displaying professionalism, knowledge, customer service and discretion in all interaction with others .

Plan and execute work in a helpful and collaborative manner.

Reporting
Analyze and develop provider reimbursement rate tables.

Research and analyze Provider fees using system generated data as well as outside data to determine discounted fee schedules.

Maintain the publication of preferred Provider listings for distribution to participants, sales personnel and other in-house staff on a quarterly basis at minimum.

Create, develop and enhance documented processes & procedures relative to Cost Containment, Contracting and Provider Relations.

Provide effective reporting of cost containment developments and Provider contract status on a regular basis .

Prepare and provide monthly management reports on participating and non-participating cost savings and performance.

Maintain necessary system generated fee schedules and other exhibits required as part of each agreement with the health care Provider on the health care processing system (HCPS).

Other
Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members.

Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.

Maintain a clean DMV record and the ability to travel to locations throughout the U .

S .

(mainly California and Arizona) up to 30 % of the time .

All o ther duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to communicate with others.

The employee frequently is required to move around the office.

The employee is often required to use tools, objects, and controls.

This noise level in the work environment is usually moderate.

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