Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

 

Primary Purpose

Responsible for directing the operations of the network development/provider relations department for Parkland Community Health Plan (PCHP) achieving full and seamless integration of all operational components eliminating variation and aligning strategic and operational processes throughout areas of responsibility. Accountable for ensuring compliance with regulatory agencies and accrediting bodies.

 

Minimum Specifications

 

Education

Bachelor’s degree in business administration, healthcare administration, or related discipline required. Master’s degree in business administration, healthcare administration, or related discipline preferred.

 

Experience

Six (6) years of client, account, or project management experience in a healthcare organization required. Five (5) years of management experience in healthcare or managed care organization required. Three (3) years of experience in provider network management or managing clinical support programs required. Three (3) years of experience working with Medicaid, Medicare, commercial network management programs, quality improvement, cost containment and/or accountable care required.

Equivalent Education and/or Experience

Seven (7) years of experience in a comparable position working in Texas Medicaid, Medicaid, or a Medicaid managed care organization may be considered in lieu of a bachelor’s degree.

 

Certification/Registration/Licensure

Project management or Six Sigma certification preferred.

 

Skills or Special Abilities

Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines and with a variety of constituents as well as the ability to articulate complex information in understandable terms. Strong understanding of provider data management, network development strategies, provider reimbursement methodologies, clinical integration, and accountable value-based care principles. Ability to demonstrate good judgement and discretion to support the provider experience. Demonstrated ability to coach and influence for results. Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships with diverse groups across and beyond the organization. Strategic thinking and long-range planning skills with the ability to lead major organizational initiatives, accomplish results, and achieve measurable outcomes or goals. Ability to work in challenging situations involving competing interests, and high level-interdisciplinary groups. Excellent time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities. Strong analytical and problem-solving skills. Knowledge of Texas Medicaid (STAR, STAR Kids/CHIP) program, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual. Working knowledge of health exchange business operations specifically the functions of utilization management, member services, claims, credentialing, and benefit plan interpretation. Familiar with Texas Department of Insurance, Office of the Inspector General as well as other state agencies involving claims and fraud, waste, and abuse programs. Functional knowledge of CPT, ICD-10, CMS 1500 professional claims, UB ancillary, and hospital clean claim guidelines. Sound business acumen. Proficient Microsoft Office and computer skills.

 

Responsibilities

             

Operations

Assist with projects impacting the business unit requiring collaboration with other key areas or serve on enterprise projects around network management. Work collaboratively with other leaders in making presentations to employer groups. Serves as business unit representative on enterprise initiatives around provider relations, provider education, value-based and health equity collaboration projects with significant impact. Coordinates communications process on such issues as administrative and medical policy, reimbursement, and provider utilization patterns Conducts proactive outreach to support the understanding of managed care policies and procedures, as well as on a variety of initiatives and programs. Coordinate, develop, conduct, or participate in external Provider Townhalls/Seminars and attends State Association conferences as requested. Serves in a leadership capacity, leading associate resources, special projects/initiatives, or provider relations and network planning. Oversees MSC relationship for vision services and collaborates with PCHP stakeholders for oversight.

             

Strategy

May provide work direction and establish priorities for field staff and may be involved in associate development and mentoring. May assist management in provider relations and network development planning. Identifies a ground-game provider relations strategy to assure regular face-to-face and virtual interaction occurs with contracted providers in the community. Supports and contributes to PCHP population health management objectives including membership growth, access management, and all clinical integration and efficiency objectives.

             

Contract Management

Conducts the most complex contract negotiations, including contracts that involve non-standard arrangements that require a high level of negotiation skills. Research issues that may impact future provider contract negotiations or jeopardize network retention. Serves as a subject matter expert for local contracting efforts or in highly specialized components of the contracting process and serves as subject matter expert for that area for a business unit. Executes contract performance management programs, e.g., service level agreements, financial incentives, compliance, and adherence and contributes to strategic network development initiatives, identifies business risks, and manages to favorable outcome.

             

Provider Relations

Develops and maintains positive provider relationships with the provider community by regular on-site and/or virtual/digital visits, communicating administrative and programmatic changes, and facilitating education and the resolution of provider issues. Serves as a knowledge and resource expert regarding provider issues impacting provider satisfaction and network retention. Researches, analyzes, and coordinates prompt resolution to complex provider issues and appeals through direct contact with providers and internal matrixed partners. Provides leadership oversight of escalated provider complaints and claim issues ensuring the appropriate resolution is achieved. Serves as a communication liaison between providers and the health plan. Coordinates Joint Operation Committees (JOC) of provider groups, driving the meetings in the discussion of issues and changes. Develops and implements network management tools, programs, policies, and procedures to drive provider satisfaction and continuous performance improvement.

             

Quality

Integrate health literacy principles into all communication including Members and Providers. Support strategies that meet clinical, quality and network improvement goals. Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed. For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination. Identifies and reports on provider utilization patterns which have a direct impact on the quality-of-service delivery.

             

Regulatory

Develop processes to maintain compliance with regulatory agencies and accrediting bodies. Ensures operations are carried out in compliance with these regulations. Works collaboratively with others to validate and sustain compliance with regulatory and accreditation standards. Conducts routine compliance audits identifying gaps and implementing remediation plans as necessary. Works collaboratively with leadership and/or PCHP Compliance to investigate and respond to matters of concern or alleged violations taking corrective action as necessary. Provides timely and accurate responses to requests for information from regulatory agencies and accrediting bodies. Assists with regulatory deliverables including, but not limited to: Annual Provider Satisfaction Surveys, CAHPS surveys, NCQA, Appointment Availability Surveys. Develops required corrective action plan implementation and monitoring education, contract questions and non-routine claim issues. Helps with HHSC reporting requirements as requested.

             

Fiscal Management and Operating Budget

Operationally responsible for the financial performance of assigned area(s). Promote activities to achieve operational efficiency. Manage the approved budget through frequent and regular monitoring. Implement written action plans to address variances adjusting strategies as necessary to meet budgetary targets. Consider operational outcomes and financial implications when making recommendations to implement new programs or modify current programs. Manage staffing levels within established targets. Prepares financial projections and conducts analysis.

             

Talent Management

Recruit and retain diverse talent with a variety of backgrounds, skills, experiences, and viewpoints that reflect the communities we serve. Promote and support a culturally welcoming, inclusive, collaborative, and highly engaged work environment where everyone feels empowered to bring their full, authentic selves to work. Accountable for orientation, ongoing education and training, and competency verification for all employees. Ensure Human Resource metrics (i.e., retention, vacancy, engagement) meet established targets. Utilize workforce metrics to monitor, identify, and respond to workforce trends. Timely completion of employee performance appraisals. Conduct regular meetings, inform team of changes in policy or procedure, and provide information regarding overall strategy and direction of the health plan. Mentor, coach, and support direct reports with building teamwork, professional development, and education to achieve optimal performance and develop talent. Ensure employee engagement survey participation rates and results meet established targets. Mandatory requirements are completed timely by employees. Required licensure, certification, and/or registry are current and in good standing for all employees. Employee performance is monitored and managed. Consult with the Office of Talent Management as appropriate regarding employee performance concerns and disciplinary action.

             

Professional Accountability

Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values. Adheres to organizational policies, procedures, and guidelines. Completes assigned training, self-appraisal, and annual health requirements timely. Adheres to hybrid work schedule requirements. Attends required meetings and town halls. Recognizes and communicate ethical and legal concerns through the established channels of communication. Works well independently and with others as an integrated team member. Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information. Maintains confidentiality at all times. Performs other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.

 

Job Accountabilities

Identifies and analyzes the design of jobs, work processes, workflows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of PCHP. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding. Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives that have been established for the department. Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of PCHP. Selects, trains, schedules, motivates, supervises, and evaluates employees making recommendations for disciplinary actions up to and including termination, to ensure maximum utilization of individual and group capabilities. Ensures that assigned employees receive opportunities to further their knowledge.

 

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.