The Provider Network Services Supervisor is responsible for the daily supervision and leadership of DHP's Provider Network Services staff, ensuring that DHP's ongoing provider relationships are maintained, and that the team is providing exceptional service to contracted hospitals, physicians, clinics and ancillary providers. This position is accountable for the strategic development of the provider network, as well as the successful on-boarding and orientation of new joint venture-network providers. The Provider Network Services Supervisor is also a key participating representative for the Network Management Division on internal DHP workgroups and committees, as the Supervisor has a comprehensive background and experience with DHP practices and the provider network. Successful management of DHP's provider networks requires focus on superior provider education/outreach, communication and problem-solving outcomes in line with DHP's provider network management practices. Position routinely interacts with executive- and management-level representatives from provider clinical, financial and business office teams. This position supports and enforces DHP's efforts to align with key providers so that network adequacy standards and practices are maintained.
Essential Job Duties:
Responsible for both provider networks planning and corrective actions/recommendations, which requires expert understanding of all DHP plan and product operations, provider reimbursement and contract terms, and, provider network management requirements for employee benefits product lines, federal/state and industry-standard insurance and managed care practices relating to medical utilization/case management, customer service, claims operations, and electronic eligibility/claims/payment transactions.
Selects, hires, develops, motivates, trains, and retains a competent staff to ensure Provider Network Services is developing, managing and strengthening relationships with DHP's key providers, other contracted providers, and network administrators.
Designs Provider education outreach program in conjunction with Provider Network Services' strategy, onsite provider visits, departmental goals, and other annual requirements. Oversees the quality and timeliness of DHP's provider network services' processes to ensure department standards are being met and to determine areas of potential improvement and/or enhancement. Leads the creation, revision and reporting out of the provider network dashboard metrics.
Works alongside the Provider Network Services Manager to plan and develop programs, including analysis of needed Provider Network Services staff resources, team structure, annual program planning, and budget development.
Raises awareness with DHP internal teams relative to provider concerns, and strives to resolve such concerns through collaborative corrective actions so that these issues are resolved. Seeks out provider intelligence to support company initiatives and implementation strategies.
Under the direction of the Provider Network Services Manager, leads joint venture and network service area expansion efforts relative to provider access, education, and on-boarding. Participates and represents the Network Management division in key DHP product line, medical policy, and operations teams.
Identifies areas where service availability is poor within the provider network, using applicable NCQA/QI policies as a guide for access to care requirements; makes recommendations to add providers/practitioners in order to meet aforementioned standards.
Makes process improvement recommendations, and works with the Senior Business Performance & Process Improvement Leader or other divisional leaders to ensure that any needed process changes are implemented, that Network Management's end-to-end processes and workflows operate seamlessly, and that policy & procedure documentation is updated.
Supports Network Management divisional leadership with the design, development, and implementation of provider network and communication strategies. Leads the development of written communications, including but not limited to: letters, provider newsletter articles, other provider updates, and educational materials for use by contracted practitioners, hospitals, and clinical staff.
Continuously develops and strengthens staff performance and employee satisfaction through use of SSM's Employee Passport, and completes staff performance reviews within established timeframes.
Acts as front line contact for practitioner and provider calls, triages calls to other DHP departments where appropriate, and collaborates with Provider Network Services Consultants and other departments to resolve issues. Coordinates communication to Network Management leadership of escalated issues where appropriate.
Maintains a thorough understanding of DHP's practitioner and facility contract provisions, as well as being able to interpret DHP contract language. Assists providers with reimbursement/payment issues based on the contract terms when applicable.
Visits provider sites on an ongoing basis to foster relationships, educate, problem solve, and perform assigned audits.
Analyzes provider surveys and feedback to identify areas for improvement by individual staff, or the overall department, to continually provide and maintain exceptional provider service.
Manages other special projects and assignments as assigned.
Provides back-up to the Provider Network Services Manager and performs other special assignments as needed.
Bachelor's degree with 5 years' experience in a managed care, insurance, or related field within the health care industry,or 7 years' experience in a managed care, insurance, or related field within the health care industry.
Minimum two years past supervisory, manager-level, or Senior Provider Network Consultant leadership experience in managing successful and high-performing teams.
Proficiency in Microsoft Office, including Outlook, Work, Excel & Power Point.
In-depth knowledge of provider billing and medical claims processing, including basic medical coding guidelines (CPT, ICD-9/ICD-10, HCPCS).
Demonstrate effective and collaborative leadership skills when coordinating provider network-related projects with other departments at DHP.
Strong negotiation, influencing and facilitation skills.
Previous experience working directly with providers to deliver services and resolve issues.
Broad knowledge of provider network management functions, including: provider network management, contracting, reimbursement, benefits administration and operations.
Ability to effectively present information to groups, make decisions in the absence of detailed instructions, and to work independently or in a team environment.
Ability to establish a rapport and interact well with individuals on all levels and to maintain a professional image and attitude.
Ability to handle multiple tasks simultaneously, meet time sensitive deadlines, and organize workload.
Excellent written and oral communication skills.
Strong analytical and problem-solving skills.
Ability to work with minimal direction and supervision.
Excellent organization and time management skills.
Excellent attention to detail.
Working knowledge of National Committee for Quality Assurance (NCQA) Provider Standards.
Prior experience working with DHP's contracted provider network.
Experience in provider contracts terms interpretation.
Familiarity with provider reimbursement methodologies: Inpatient DRG, Outpatient surgical groupers, fixed rate fee schedules, per diem rates, etc.
Previous claims and/or medical management operations experience.
Knowledge of Trizetto's QNXT and/or Hewlett-Packard's MetaVance administrative systems.
You’ve known us as many names throughout St. Louis, and now, we’re bringing our hospitals, doctors, home care and other services together under one name – SSM Health. With seven hospitals, 350+ physicians, more than 40 physician locations and 12,000 employees, we are part of something bigger and better. We’re connected to a wealth of resources, expertise and advance technology to help you, your fa...mily and our community live long, healthy lives.
We’ve grown and changed a lot over our 143-year history. Our name may be changing but our mission remains the same