Manager of Provider Operations

Care Management Irvine, California Irvine, California


Description

You spend more than half of your waking hours working. Make these precious, fleeting moments matter by working for an organization and a cause you can believe in. 

Western Growers exists for one reason only: to ensure the future viability of its members – the hard-working, salt of the earth farmers who grow the fruits, vegetables and tree nuts that feed our nation and nourish our bodies. But their way of life, their ability to pass their multi-generational farms and family legacies on to their children and grandchildren, is being jeopardized by a host of threats, many of them beyond their control. They face a growing litany of laws and regulations that make it increasingly difficult and expensive to do business. 

Our members depend on us to help them remain competitive and profitable in spite of these trying circumstances, which we do by fighting – heart and soul – for them every single day. We passionately advocate for them in the halls of Congress and on the steps of the state capitol. We actively facilitate the advancement of technology designed to help them become more efficient and less dependent on diminishing resources. We diligently provide health insurance to their farm workers, as well as other insurance solutions tailored to the unique business. We do all of this, and more, from a position of leadership in the agriculture industry, which requires a team of intelligent, inquisitive and innovative individuals sold out for our common purpose.

To learn more watch our Company Video!

Job Description Summary

This position reports to the Vice President of Health Management 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, 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. The Manager 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 exempt 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 years of experience in healthcare contracting field with management and supervisory experience preferred.
  • Demonstrated ability in leading and directing staff in the area of Provider Contracting and Network Development.
  • High degree of knowledge and experience in pricing development and negotiation skills for physicians, hospitals, dentists and other ancillary providers.
  • Intermediate knowledge in the structure and development of provider networks and related pricing models.
  • Intermediate skill level in Microsoft Office Suite.
  • High level of problem-solving capability with the ability to be decisive and take action as necessary.
  • Ability to prioritize multiple tasks and projects, with attention to detail.
  • Excellent written and oral communication skills, as well as interpersonal skills.
  • High ability to self-direct, exercise initiative, and seek guidance when appropriate
  • 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 and manage provider contracting efforts and partnerships to achieve quality, cost management, 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.
  • Negotiate and build a stable provider network that achieves objectives for unit cost performance and trend management and produces an affordable and predictable healthcare insurance product.

Provider Contracts Management

  • 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.
  • 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.
  • Maintain confidentiality and comply with HIPAA rules and regulations.
  • Develops and maintains ongoing reporting on contract status.

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, on a quarterly basis, focused on their 3A+ capabilities, impact and effort.
  • Make decisions and choices, impacting staff, by using the: selection and hiring, clarifying roles and objectives, managing performance, correction & discipline and termination 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 associate to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the associate is regularly required to talk or hear. The associate frequently is required to stand, walk and sit. The associate is frequently required to use hands to finger, handle, or feel objects, tools, or controls and reach with hands and arms. The noise level in the work environment is usually moderate.