To manage daily operations of the Provider Relations department including personnel and operational responsibilities. Ensure PR department is compliant with regulatory requirements and network reporting. Coordinate NCQA activities with QI department. Primary liaison with Northern Region office staff.

• Provide day-to-day oversight to Provider Relations staff.
• Facilitate daily operations with Northern Region office staff.
• Responsible of overall management of PR staff and department operations.
• Assist with provider network development/contract negotiations as needed.
• Ensure accuracy of provider data is met and maintained.
• Monitor and establish PR department production standards.
• Assist with compliance of DHCS, DMHC, and CMS regulatory requirements.
• Conduct provider orientations and trainings as needed, requires public speaking.
• Attend Committee meetings, internal and external.
• Oversee and monitor the Member Grievance Review process to ensure deadlines are met.
• Monitor credentialing and re-credentialing process and activities.
• Liaison for Peer Review activities with the Chief Medical Officer as related to credentialing.
• Assist with development and tracking of PR department annual financial budget.
• Interview and select qualified candidates for Provider Relations department.
• Monitor and evaluate performance of direct reports.
• Complete staff performance evaluations.
• Train staff and provide staff development.
• Develop written department policies and procedures.
• Work with PR management to ensure staff performance standards are consistently met.
• Assist with implementation of new technology.
• Responsible for Provider Directory maintenance and accuracy per Federal and State regulatory requirements.
• Prepare weekly, monthly, and quarterly reports for internal and PHC dashboard reporting.
• Point person and liaison with IT and Compliance department staff for Federal and State mandates and regulatory requirements.
• Recruit qualified staff to ensure PR department meets and maintains NCQA standards, DHCS, and CMS regulatory requirements and other Federal or State laws regarding managed Medi-Cal plans.
• Monitor accuracy of provider materials and information on PHC website.
• Conduct PR department staff meetings.
• Participate in PR department quality improvement projects.
• Project Management.

SECONDARY DUTIES AND RESPONSIBILITIES

• Act on behalf of the Senior Provider Relations Director.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$180,252.50 - $243,340.87

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.