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Network Manager - Provider Contracting

Primary Location Atlanta, Georgia Job Number 1086281 Date posted 06/28/2022
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Description:
Job Summary:

Ensures successful contractual relationships with hospitals and community providers. Acts as a liaison between contracted hospitals and Kaiser Permanente to address issues relating to contract administration. Oversees and directs the day to day operations of the provider relations unit. Responsible for peer review, coaching and development of provider relations representatives. May provide input on performance evaluations and participate in goal development.

Essential Responsibilities:


  • Promotes good provider relations by addressing operational issues and evaluate contract and credentialing compliance.

  • Attends Joint Operating Committee meetings as assigned.

  • Responsible for contracting with Hospital Based Physicians.

  • Responsible for the Letter of Agreement Process.

  • Tracks and maintains any CPI increase for contracted hospitals.

  • Communicates with consultants to provide up-to-date information regarding TSPMG.

  • Provides feedback to the appropriate management personnel when issues are identified relative to patient care, billing and authorization.

  • Works closely with Department of Quality Risk Management, Business Office, Claims and Medical Audit to identify and resolve operational issues relating to contract development, administration, and to facilitate quality of service and reimbursement.

  • Responsible for implementation of newly developed contracts by providing on site training and orientation to the community providers office staff.

  • Provides support to the Contract Manager in regards to capitation arrangements with Core Consultants.

  • Responsible for the analysis and evaluation of metrics to evaluate key business indicators including timeliness and accuracy of contract configuration. Contributes to metrics and analyses for the purposes of vendor oversight, network adequacy (accessibility & capacity), member satisfaction, vendor integrity, business continuity, product recall, etc. and determining appropriate next steps. Oversees development of vendors corrective action plans and ensures submitted plans meet quality and business process standards. Accountable for ensuring vendors/suppliers are responsive to quality and service level concerns and influencing stakeholders to ensure that interventions are timely and effective.

  • Responsible for development and maintenance of positive ongoing relationships with community providers. Serves as the key contact for community providers in resolving escalated complex claims concerns and achieving provider satisfaction. This position is also responsible for the regular monitoring, collection, and reporting of performance metrics, territory profile reporting of field operations activities, and the coordination of Kaiser Permanente Payor/Provider conference activities.

  • Responsible for the community provider orientation and training process (large and small audiences):
        1. Creates trending reference and training materials as needed for different audiences / training topics;

        2. Delivers training and orientation classes using appropriate training techniques

        3. Provides accurate, timely expertise in KP products and operations;

        4. Creates training topics identified from escalated provider concern trends

        5. Maintains personal knowledge of product and benefit developments, and organizational and departmental policies and procedures

        6. Utilizes approved and branded KP training materials

  • Coordinates with PMG with the orientation of external providers to Kaiser Permanentes patient management guidelines including authorization and referral processes.

  • Resolves escalated provider concerns and problems:
        1. Performs provider field visits to address escalated complex provider issues communicated via Macess SFs

        2. Demonstrates focus on customer satisfaction with excellent service and efficient follow up

        3. Performs detailed analysis of operational issues

  • Negotiates with other operational departments to implement resolution.

  • Responsible for creating and on-going maintenance for provider manuals, ordering guides and other tools relating to provider contracts used by medical centers and other stakeholders to meet member needs.

  • Position is responsible for contract implementation activities including configuration of contracts with regional claims and self-funding Third Party Administrators, supplier/facility initial orientation, notification to internal stakeholders regarding network composition changes, etc.

  • Assists in pre-credentialing and re-credentialing activities for affiliated providers. Position manages operational and patient specific contractual disputes with contracted vendors. Facilitates with regional claims department investigation of under/overpayments and other activities related to claims adjudication.

  • Coordinates with Legal, Benefits, Medicare Compliance & Medicaid Department to update required service changes.

  • Formulary & contract consultant/SME for all grievances and appeals.

  • Provide for contracted provider dispute resolution.

  • Assists department management in establishment of partnership with other regional departments.

  • Assist with targeted effort as part of KPs strategic goals.

  • Provides accurate, timely expertise in KP products and operations.

  • Creates training topics identified from escalated provider concern trends.

  • Maintains personal knowledge of product and benefit developments, and organizational and departmental policies and procedures.

  • Utilizes approved and branded KP training materials.

  • Coordinates with PMG on orientation of providers to Kaisers patient management guidelines including authorization and referral processes.

  • Resolves escalated provider concerns and problems.

  • Performs Field in person Provider visits to address escalated complex provider issues communicated via regional data base tracking systems (i.e. MACESS CSFs ) if applicable.

  • Demonstrates focus on customer satisfaction with excellent service and efficient follow up.

  • Performs detailed analysis of operational issues.

  • Negotiates with other operational departments to implement resolution.

  • Conducts issue analysis and evaluation, identifies process improvements in Provider Relations and other operational departments to address root causes of escalated inquiries, providing proposed solutions, when possible.
Basic Qualifications:
Experience


  • Minimum two (2) years of experience in a field position doing provider relations.

  • Minimum two (2) years of experience in a field position.

  • Minimum two (2) years of public speaking and presentation skills.

  • Minimum two (2) years of provider contracting experience.

  • Experience in billing department protocol and procedures.

Education

  • Bachelors degree required, OR four (4) years of experience in a directly related field.
  • High School Diploma or General Education Development (GED) required.
License, Certification, Registration
  • N/A
Additional Requirements:

  • High ethical standards.
  • Proficient in Excel and Word.
  • Thorough knowledge and understanding of provider relations, physician reimbursement and managed care contracts.
  • Knowledge of physician office operations (example::CPT-4 codes, ICD-9 codes, capitation etc.).
Preferred Qualifications:

  • Minimum five (5) years of experience in Health Care Administration, Managed Care Contracting or Health Care finance is preferred.
  • Knowledge of Medicare, Medicaid, regulatory requirements and practice protocols.
  • Knowledge of quality assurance and utilization management concepts.
  • Knowledge of KFHP contracting process, benefits coverage, QA goals and objectives, medical referrals processing procedures.
  • Bachelors degree in nursing.
Primary Location: Georgia,Atlanta,Regional Office - 10 Piedmont Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 08:00 AM Working Hours End: 05:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: NUE-GA-01|NUE|Non Union Employee Job Level: Individual Contributor Department: Regional Office - 9 Piedmont - Rgnl Pres-Contracting - 2808 Travel: No Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.