Manager, Provider Relations - The Health Plan - Bellaire, TX

 
Position: Manager, Provider Relations - The Health Plan - Bellaire, TX

Job ID: 143571

Location: US-TX-Bellaire, US-TX-Houston

Department: PROVIDER RELATIONS SS/LTSS

Talent Area: Professional - Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p Monday - Friday

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 13,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.

Summary:

We are searching for a Manager of Provider Relations – someone who works well in a fast-paced setting. In this position, you will plan, direct and maintain strategies that assure harmonious relationships are established and maintained with physicians and other providers and efficient, effective care is delivered to membership. You will educate providers through service programs that review policies and procedures physicians are obligated to adhere to, discuss physician feedback as necessary and promote continuing education classes and other educational programs that support the goals and objectives of the health plan.

 

Think you’ve got what it takes?



Responsibilities :

  • Supervises a staff responsible for development of a regional territory inclusive of provider selection and satisfaction as well as member growth and medical loss ratio
  • Acts as an internal and external liaison for the hospital to resolve managed care issues, contract implementation, contract interpretation, and maintaining positive relationships with providers and primary HMO’s through understanding territory demographics and health service needs
  • Actively involved in community activities of territories in their region including political, educational, health related and recreational related groups
  • Conducts territory assessment in conjunction with staff and develops strategic plan for service area based including interventions to meet growth projections of membership and influence medical loss ratio
  • Assures compliance with TDI rules and regulations as they relate to network accessibility & provider credentials
  • Evaluates provider use/billing for patterns demonstrating best practice
  • Represents Provider Relations at various meetings, both internal and external which includes the IDS, stakeholder meetings, HHSC and TDI
  • Investigates complaints, documents findings and makes recommendations that adjudicate the complaints so that the health plan is in compliance with TDI, HHSC and any other regulatory agencies as appropriate
  • Serves as Team Leader for various special projects as assigned by the Assistant Director related to strategic initiatives in regional territories
  • Extensive analytical responsibility included in assessment and reassessment of activity within territories that may influence health delivery, membership growth and/or access to care


Qualifications:

  • High School Diploma or GED
  • Eight (8) years of health care or managed care experience (A bachelor’s degree may be substituted for four (4) years of experience, and an associate’s degree may be substituted for two (2) years of experience.)
  • Current U.S. driver’s license is required for all new hires/transfers effective 08/01/16
  • Current personal motor vehicle insurance is required for all new hires/transfers effective 08/01/16
  • Knowledge of managed care industry and the working philosophy for its success, cultural competence, rules and regulations that affect a HMO in the state of Texas including clean claims laws, rules and regulations
  • Ability to effectively communicate to a broad spectrum of employees and providers
  • Required skills include proficiency with computer word-processing, spreadsheet, and database software
  • Candidate should possess exceptional verbal and written communication skills, as well as a high level of interpersonal skills
  • It is necessary to have substantial writing experience.

 



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