Manager, Provider Contracts

Provider Operations Irvine, California Irvine, California


Description

Western Growers Assurance Trust (WGAT) was founded in 1957 to provide a solution to a need in the agricultural community — a need for employer-sponsored health benefit plans not previously available from commercial health insurance carriers. WGAT is now the largest provider of health benefits for the agriculture industry. The sponsoring organization of WGAT is Western Growers Association, created in 1926 to support the business interests of employers in the agriculture industry. WGAT’s headquarters is located in Irvine, California.

WGAT’s mission is to deliver value to agriculture-based employer groups by offering robust health plans that meet the needs of a diverse workforce. By working at WGAT, you will join a dedicated team of employees who truly care about offering quality health benefits and excellent customer service to plan participants. If you want to start making a difference working in the health care industry, then apply to WGAT today!

To learn more watch our Company Video

Job Description Summary


This position reports to the Assistant Vice President of Operations (AVP) and is responsible for managing Western Growers Assurance Trust’s (WGAT) and Pinnacle Claims Management Inc. (PCMI) staff, policies and procedures in the area of Provider contracts for health care services, both third party networks and direct contracts/providers, third-party vendor operational policies, objectives, and initiatives. This position is responsible for negotiating contracts for the provider network (hospitals, physicians, and ancillary groups) yielding a competitive and stable network as well as pricing out of network claims. The Manager, Provider Contracts is also tasked with developing and maintaining strong business relationships with hospitals and providers. This position has direct supervisory responsibilities for a team of two employees in the following roles: Provider Network Manager and Provider Relations Specialist.

Qualifications

  • Bachelor's degree in Business, Health Care Management or related field and a minimum of five (5) years of experience in healthcare contracting field, plan procedures & policies preferred.
  • Minimum of five plus (5+) years with management and supervisory experience leading and directing teams and projects.
  • Three plus (3+) years of experience developing pricing and utilizing financial modeling and analysis in making rate decisions and negotiating contracts involving complex delivery systems and organizations.
  • Three (3+) years of experience in performing network adequacy analysis, structure, and development of provider networks.
  • Experience in developing and managing key third party networks & provider relationships.
  • High degree of knowledge and experience in contract language, pricing development, financial acumen, contract negotiation for physicians, hospitals, dentists and other ancillary providers.
  • Intermediate level of knowledge of claims processing systems and guidelines.
  • In-depth knowledge of Medicare Resource Based Relative Value System (RBRVS), Diagnosis Related Groups (DRG), Ambulatory Surgery Center Groups, etc.
  • Intermediate skill level in Microsoft Office Suite (Excel, Outlook, Word, and PowerPoint).
  • Superior problem-solving, analytical and critical thinking skills results oriented with the ability to be decisive and take action as necessary.
  • Ability to influence both sales and provider audiences through strong written and verbal communication skills. Experience with formal presentations.
  • Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. (mainly California and Arizona) up to 30% of the time.

Duties And Responsibilities

Provider Network Development

  • Develop the provider network through contract negotiations, relationship development and servicing.
  • Manage provider contracting efforts and partnerships to achieve quality, cost management, network adequacy and strategic business development objectives.
  • Interface with personnel at all third-party provider network organizations for high-level resolution of vendor contracts, network management, and pricing issues.
  • Develop a provider network comprised of physicians, hospitals and ancillary groups that is competitive and provides broad healthcare access to patients.
  • Accountable for network adequacy across lines of business for all geographies in which the organization provides network services.
  • Create and analyze multiple types of reports, including network adequacy, provider performance, provider rosters and department dashboards.
  • Act as the final escalation point for provider issues and complaints. Research problems and negotiates with internal/external partners/customers to resolve highly complex and/or escalated issues.
  • Conduct annual review process that ultimately determines network contracting strategy each year, which includes establishing a detailed plan for each major contracting strategy and entity.
  • Work on projects impacting the business unit requiring collaboration with other key areas or serve on enterprise projects around network management.
  • Track performance at a contract and network level to support strategic decisions in partnership with analytics and operational teams.

Provider Contracts Management

  • Serve as local market expert supporting (and managing when necessary) the provider onboarding process and provider updates submitted by provider offices within defined market.
  • Develop contract rate methodologies to use in provider negotiations for Medical, Dental, Vision, and Hospital services.
  • Lead negotiations for key contracts and ensure all contracting strategies are being executed timely and appropriately.
  • Negotiate Medical, Hospital, Dental, and Vision provider contracts to maximize savings for select product lines unique to WGAT and PCMI.
  • Interpret provider contracts for health care services and develop necessary processes to implement on Health Care Processing System (HCPS) for provider structure and rates to allow automated pricing.
  • Resolve Internal Revenue Service (IRS) requests, 1099 issues, and levies to ensure compliance with IRS guidelines including the maintenance of W-9 forms.
  • Assist with impact analysis of pricing decisions regarding negotiated payment rates for network providers.
  • Assist in constant analysis of contracting needs including the assessment of claims and utilization data to identify areas for new and re-negotiated contracts.
  • Responsible for pricing out of network claims in California and other states using appropriate pricing schedules.
  • Renegotiate claims on behalf of PCMI clients or WGAT to achieve savings for the client or Trust.
  • Work closely with the claims department to ensure claims are paid according to negotiation outcomes.
  • Develop and maintain reports on cost savings and contract discounts and compares them to other networks to position the company advantageously in the marketplace.
  • Initiate and maintain effective channels of communication with matrix partners including but not limited to, Claims Operations, Health Care Management, Provider Maintenance, Cost Containment, Legal, Compliance, Sales, Account Managers and Customer Service.

Process Improvement

  • Identify and implement process improvements to increase operating efficiency.
  • Plan, deploy, and lead all lean activities that will produce significant cost savings through productivity, quality, waste reduction improvements, and improving business processes.
  • Oversee and guide the development of comprehensive process improvement plans to be shared with stakeholders.
  • Analyze, track and trend department performance; identify any potential service or systems issues; implement interventions and determine success of intervention.
  • Regularly analyze and report on the productivity and effectiveness of the operations in comparison to established performance metrics. Identify areas of improvement and recommend resolution.
  • Develop and maintain appropriate and necessary departmental policies, procedures, objectives, and activities relating to improving organization performance.
  • Manage cross-functional communications across operations stakeholders as new solutions and identified and implemented.
  • Monitor performance to ensure contract compliance by internal departments/medical providers.
  • Implement “system of controls” as called for in State, internal and regulatory audits related to and operational controls. This included verification that controls are operating effectively, trending and risks are identified.
  • Proactively work on developing and designing work orders that will assist the team in streamlining processes and follow through with implementation and testing for final release.

Management & Leadership

  • Develop, manage, and lead a team of 3A+ self-accountable professionals.
  • Develop a culture of real, personal accountability by modeling the behavior that defines it.
  • Instill a culture of safety and expectation, within your respective area/s.
  • Require direct reports to hold themselves accountable to high standards of performance and personal conduct, in a clear, helpful, straightforward way.
  • Conduct one-on-one conversations with every direct report, quarterly, focused on their 3A+ capabilities, impact, and effort.
  • Make decisions and choices, impacting staff, by using the steps as outlined in the “Outward Mindset Skills for Leaders” guide.

Other

  • Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data
  • Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results
  • Maintain a clean DMV record and the ability to travel to locations throughout the U.S. (mainly California and Arizona) up to 30% of the time.
  • All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.