Upper Peninsula Health Plan

The provider relations manager is responsible for leading and managing a team of provider relations representatives, claim service representatives, and a quality review specialist to develop and support strong relationships with network providers. The provider relations manager and team help ensure provider compliance, resolve provider concerns, facilitate provider training and education, and support provider satisfaction. This position is responsible for provider network contracting and management, improving access and quality of care for our members. The provider relations manager ensures team members remain up-to-date on Federal and State rules, regulations, and policies and creates or modifies departmental policies and procedures to ensure compliance. Ensures department achieves annual goals and objectives. 

1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.

 

2. Responsible for hospital and physician network development and management; establishes a network access plan, conducts recruiting activities, and oversees the recruitment efforts of team members. 

 

3. Develops and recommends policy change related to provider recruitment and contracting to ensure compliance with State and Federal requirements and in support of corporate initiatives. 

 

4. Responsible for delegating work among the provider relations team, problem solving, motivating, and supporting the provider relations team so they may achieve peak productivity and performance. 

5. Supervises provider relations team; responsible for scheduling of time off to ensure adequate coverage, coordinating new employee orientation, and conducting 90-day and annual performance appraisals in compliance with UPHP employee policies. 

 

6. Serves as the plan liaison to the provider community, which includes, but is not limited to: arranging provider education and training, updating website content, distributing provider materials, and resolving individual provider complaints in a timely manner. 

 

7. Assists in the facilitation of Provider site visits as required.

 

8. Responsible for the accuracy and timely management of all provider contracts and ensures provider contracting is consistent with applicable claim payment methodologies. 

 

9. Augments and modifies the provider network to comply with network adequacy standards, including those set forth by the Centers for Medicare and Medicaid Services (CMS), Michigan Department of Health and Human Services (MDHHS), and accrediting agencies. 

10. Analyzes and monitors provider claim compliance with Plan policies and procedures and recommends solutions when problems occur.

 

11. Conducts and prepares reports on annual provider satisfaction surveys; develops plan to improve identified areas of concern; works with other departments to develop quality assurance initiatives based on survey results.

 

12. Supports quality management and company-wide quality initiatives such as Healthcare Effectiveness Data and Information Set (HEDIS®), Consumer Assessment of Health Plans (CAHPS), and National Committee for Quality Assurance (NCQA). Responsible for ensuring continuous compliance with NCQA standards related to provider network.

 

13. Maintains confidentiality of client data.

 

14. Performs other related duties as assigned or requested.

 

Bachelor’s degree in healthcare administration, public health, business, or related field. 

 

Master’s degree in business or health-related discipline such as health care administration or 

health care management.

Three (3) years of experience in provider relations, network management, or healthcare 

operations; one (1) year of supervisory experience required. 

 

Three (3) years of experience in provider relations, network management, or healthcare 

operations in a Medicaid managed care organization or health plan; three (3) years of supervisory 

experience preferred. 

 

Proficiency in Microsoft Office 

Ability to analyze data and develop reports

Excellent problem solving, negotiation, and conflict resolution skills

Excellent human relation and oral/written communication

Excellent organizational and prioritization abilities

 

Proficiency in a provider management system

Knowledge of MS PowerPoint 

Knowledge of state Medicaid guidelines and CMS regulations

Knowledge of Medicaid reimbursement models, managed care contracts and regulatory requirements 

Understanding of quality improvement programs

 

[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:

 

Ability to enter and access information from a computer

Ability to access all areas of the UPHP offices

Occasionally lifts supplies/equipment

Prolonged periods of sitting

Manual dexterity 

Works in office conditions, but occasional travel may be required

Exposure to situations requiring exceptional interpersonal skills or periods of intense concentration

Subject to many interruptions

Occasionally subjected to irregular hours