This position reports directly to the Chief Financial Officer (CFO) and is responsible for the leadership and strategies for all Provider Services and assuring best in class quality of service for Providers within the CenterLight Provider Networks. The Vice President of Provider Relations will need to establish strong working relationships with key providers and work closely with all pillars within the organization (Clinical Innovation, Care Delivery, Mission Excellence and Strategic Development & Growth).
Responsibilities - Responsible for day to day operations in the department to ensure a strong positive relationship with contracted providers, vendors and plan members.
- Manage the Provider Services Staff and develops and implements the strategy to best educate contracted providers about policies and procedures as well as special initiatives.
- Oversees the development of necessary documents and materials including: Provider Manual, Provider Directory, Orientation and Reference Guides, Provider Quarterly Newsletter and other provider correspondence.
- Provides oversight of credentialing and re-credentialling of provider network as well as for delegated functions.
- Ensures that departmental/agency operates within established financial guidelines.
- Establishes and evaluates criteria for vendor selection and performance.
- Participates in selection of required products/services and acts within prescribed agency/organization guidelines.
- Monitors performance of external resources (Providers, Vendors etc) to ensure requirements are met.
- Integrates department services into the organizationtrategic mission by setting goals that align with the mission and monitoring progress toward goals.
- Oversees all provider services departments and communications explaining benefits, policies and procedures for all applicable product lines and establishing standards for provider orientations, onboarding, re-education, roll-out/introduction or new initiatives and compliance
- Oversee the quality of the provider relations department responses to inquiries and claims issues, participates in problem resolution with internal and external providers. Identifies and monitors provider issues and concerns, recommends solutions and follows up with provider during the process as well as communicates resolution to ensure problems have been resolved.
- Participates on the Business Development Council, makes recommendations for development strategy and growth and assists in the contracting process for both execution of new contracts and the renewal of existing contracts
- Assures accuracy of provider directory and network reports. Responsible for producing Quarterly and Annual HPN files, Hedis report on board certification, Part C reporting on network adequacy, and coordination of GeoAccess reports to meet network adequacy. Produces internal process for working with IT and compliance on reports and responds to regulatory requests, including requests part of internal and external audits.
Qualifications Education: Bacheloregree in Health Care field related preferred.
Experience: A minimum of five years) experience in Medicaid/Medicare, Managed Care is required. Management skills required and a strong working knowledge of Provider Relations policies and procedures.
License/Registration: N/A
