Job Description
Job Description
Overview
The Provider Network Manager is responsible for maintaining and enhancing provider networks within an assigned territory through provider relations, network development, and routine contracting activities. The Provider Network Manager serves as a primary contact for contracted providers, conducts provider education and outreach, identifies and addresses network opportunities, and supports provider recruitment efforts. The position also monitors market changes and network performance to ensure adequate provider coverage and compliance with CMS network adequacy standards and all applicable regulatory requirements.
Responsibilities
- Manage provider relationships within assigned markets, serving as a primary point of contact for contracted providers and addressing network-related issues and inquiries.
- Perform routine provider contracting and recruitment activities to support network growth, address coverage gaps, and maintain adequate provider access.
- Conduct provider education and outreach activities to promote provider engagement, communication, and understanding of health plan requirements and initiatives.
- Monitor and report market and provider changes that may impact network performance, access, or compliance within assigned territories.
- Collaborate with internal departments to resolve provider issues, support operational initiatives, and improve network effectiveness.
- Promote a positive and collaborative work environment that supports continuous improvement and organizational success.
- Complete all assigned corporate responsibilities, including compliance training and other organizational requirements.
Qualifications
- Associate’s Degree or equivalent work experience.
- Five (5)+ years of experience in managed care, provider network development, provider relations, contracting, or a related healthcare field.
- Prior experience with Medicare Advantage plans required; Institutional Special Needs Plan (I-SNP) experience preferred.
- Experience building and maintaining provider relationships, conducting provider education, and supporting provider engagement initiatives.
- Reliable transportation.
- Current automobile insurance which meets company policy requirements.
- Familiarity with health plan operations, including benefits, claims review and resolution, eligibility, provider data management, and network operations.
- Knowledge of CMS network adequacy standards, provider recruitment, and regulatory compliance requirements preferred.
- Strong organizational, presentation, and time management abilities.
- Effective communication skills.
- Working knowledge of Medicare payment methodologies.
- Ability to follow instructions and work independently to achieve goals and complete assignments.
- Proven success working collaboratively in a team environment.
- Proficient in Microsoft Office Suite and other relevant computer applications.
- Self-motivated, dependable, team-oriented, and goal-oriented.
- Skilled at managing multiple priorities effectively.
- Travel up to 25%