Manager, Provider Support Services/Response - The Health Plan

 
Position: Manager, Provider Support Services/Response - The Health Plan

Job ID: 145247

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

Department: PROVIDER RELATIONS RESPONSE

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p Mon - Fri

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 Support Services and Response – someone who works well in a fast-paced managed care setting. In this position, you’ll 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 be responsible to educate providers through in 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.


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Responsibilities :

Job Duties & Responsibilities

 

• Conducts claims payment assessments in conjunction with staff to identify and address issues with over or underpayment, elements requiring configuration change and issues to address in communication campaigns with providers and develops plan for claim or requirement based communication and action including interventions to influence medical loss ratio
• Produces trended correlation of medical use to facilities and assigned delegated provider groups
• 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
• Assures compliance with all regulatory and accreditation rules and regulations as they relate to network accessibility, professional services, and coordinate responses to Health and Human Services provider complaints with claims director, business systems assistant director and contracts director
• 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 network that may influence health delivery, membership growth and/or access to care
• Ensures compliance with State and Federal guidelines in communications to providers including provider manuals, online tools, education materials and presentations



Qualifications:

Skills & Requirements

• H.S. Diploma or GED
• 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



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