• Provider Network Manager - TriWest

    Location US-IA-Des Moines
    Job ID
    213296
    Category
    Clinical/Provider Support
    Requires Non-Compete?
    No
  • Job Summary

    About The Team: The Network Administration department is a diverse team that leads the development and implementation of policy for provider credentialing, recredentialing, and for network participation through provider agreements. In addition, the department is responsible for provider data collection, management and reporting, they lead provider data system configurations to support Wellmark's health networks and enterprise projects, they lead efforts in provider communication and education, and they support other related initiatives, such as TriWest.

     

    About the Role: As Provider Network Manager, you’ll serve in a brand new key execution role that drives the completion of corporate and strategic priorities. You’ll be responsible for leading Wellmark’s TriWest initiatives, such as oversight and direction of the program related to our TriWest agreement. In addition, you’ll work collaboratively with Health Networks, Network Administration, Network Economics, and other internal departments to achieve stated objectives, measurable goals and the delivery of these initiatives.

     

    About You: Ideal candidates are at their best when they’re at the heart of the action—they’re the subject matter experts we turn to when we have questions about complex programs, policies/agreements, or processes. Why? Because they love to understand how things work, they're detailed, and they exercise strong critical thinking skills. They’re also connectors of people and processes, liaisons who thrive on driving results forward together with others.

    Minimum Qualifications Required (all must be met to be considered)

    • Bachelor’s Degree or direct and applicable work experience.
    • 2+ years of related experience independently coordinating, managing, and evaluating complex projects or programs; OR health Insurance, managed care, State, or Federal health care program experience, including knowledge of applicable policy, regulation, or accreditation.
    • Excellent critical thinking skills and the ability to identify/research issues and make appropriate decisions. Understanding of applicable rules, regulations, guidelines, and implications to department.
    • Effective verbal and written communication skills, including the ability to communicate across multiple levels of the organization, externally, and with technical and non-technical stakeholders. Strong group facilitator.
    • Ability to effectively consult, build relationships, influence, and solicit cooperation from stakeholders. Understands the needs of others, asks meaningful questions, distills information into relevant insights, and develops actionable solutions.
    • Proactive self-starter with effective time management skills. Ability to organize and prioritize competing projects or tasks. Flexible and adaptable to change. Strong attention to detail.
    • Proficiency with Microsoft Office. Technical aptitude to learn new systems quickly.

    Hiring Specifications Preferred

    • Bachelor’s Degree.
    • Formal project or program management experience; PMP certification is a plus.
    • Managed Care, State or Federal health care program (e.g., Medicaid, Medicare, TRICARE) project leadership experience.
    • Presentation skills.

    Job Accountabilities

    a. Serve as the business lead and relationship manager with TriWest. Responsible for operational coordination with internal Wellmark stakeholders across a variety of business areas i.e. IT, Health Networks, Network Administration and Network Economics.

    b. Establish and maintain effective relationships with stakeholders across the business areas, including leadership, and effectively coordinate activities that support TriWest. Responsible for ensuring contractual and regulatory requirements are met, while continuously looking to enhance the service offering to best align with Wellmark and member needs.

    c. Serve as a resource and subject matter expert for TriWest policies, procedures and operations. Support provider data accuracy for TriWest's provider directory, including developing and generating reports on a regular and as requested basis. Ensure that provider data is submitted accurately and timely to TriWest, or to other business partners as applicable.

    d. Ensure adherence and compliance with contractual or regulatory obligations. Will monitor and ensure compliance with NCQA, URAC and other applicable accreditation requirements while working closely with the Accreditation team. Maintain access and network adequacy standards working with Health Networks for URAC, CCN and the PC3 programs.

    e. Assist leadership with managing and coordinating vendor business relationships including but not limited to monitoring of day to day activity against Statement of Work SOW service level agreements SLAs, reconciliation/validation of invoices, collaboration with vendors on business process changes, and resolution of issues. Collaborate with vendor management on escalated issues.

    f. Coordinate and ensure regular reporting as required by TriWest's Health Network contract is completed timely. Liaison with a variety of business areas to obtain and track compliance for auditing and reporting purposes. Will also monitor credentialing reports on delegation status working closely with the Delegated Credentialing Liaison.

    g. Coordinate and design provider education sessions regarding TriWest programs working closely with Network Engagement business partners. Will also develop, implement and maintain program level playbook including documenting all desk level procedures and overall program policies and guidelines for TriWest.

    h. Other duties as assigned.

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