Provider Network Manager Position Available In Swain, North Carolina

Provider Network Manager 3.5 3.5 out of 5 stars 1 Hospital Rd # C-268, Cherokee, NC 28719

Job Title:

Provider Network Manager Job Code:

PNM Department:

Infrastructure Development Division:

Tribal Option Salary Level:

Exempt 5 Reports to:

Assistant Director of Managed Care Last Revised:

May 2025 Primary Function The Provider Network Manager will report to the Assistant Director of Managed Care of the Cherokee Indian Hospital Authority (CIHA). The Provider Network Manager, under the leadership of the Assistant Director of Managed Care, and following a matrix team model, will be responsible for developing and managing the operations of a healthcare provider network in accordance with all North Carolina Department of health and Human Services’ requirements and provider network requirement found with 42 CFR 438 governing managed care operations and as outline in the

NCDHHS/EBCI

Tribal Option Contract. The position must work collaboratively across the organization to develop the CIHA provider network strategy plan to ensure that the Tribal Option network of enrolled providers is adequate to meet contractually defined network adequacy standards and delivers high quality healthcare services to all members of the Eastern Band of Cherokee Indians. The position is responsible for establishing and maintaining processes and systems related to provider network development including contract management, credentialing and monitoring. Oversees network recruitment, performance and compliance with applicable contract standards. Additionally, the position recruits, hires, trains, and measures performance of staff. May be involved with the design and operations of database systems used to manage provider data and produce reports related to network adequacy and program outcomes. Job Description Administration Under the direction of the Assistant Director of Managed Careensures that the guiding vision, mission and values are incorporated into development and operations of the Tribal Option’s network management plan and division. Provides direct supervision to the Contract Liaison of the EBCI Tribal Option and staff assigned to network operations. Develops in collaboration with other leadership members, statistical, data and management information reports to analyze and evaluate effectiveness and value outcome of provider delivered services. Educate the Tribal leaders, the community, and key stakeholders on the mission and functions of the Tribal Option. Maintains an effective organizational structure and communication flow that ensures that leadership staff have the necessary information and capacity required to manage in a highly complex, at-risk, regulatory environment. Provides leadership, supervision, and professional growth opportunities to direct reports. Ensures network management functions achieves readiness to obtain national accreditation for health plan management functions and develops and maintains infrastructure and systems to monitor ongoing compliance with standards. Monitors effective network performance and compliance as it relates to all Medicaid, local, State, and Federal laws, and regulations. Ensures provider-contracting process is executed in compliance with terms and conditions of

NCDHHS/EBCI

Tribal Option Contract. Prepare reports as required and requested. In conjunction with the CIHA Medical Director establishes quality standards and review process to evaluate all providers who have been successfully credentials and re- credentialed thought the state centralized credentialing agency, prior to executing contracts. Serves as the primary point of contact for the states Credentialing Vendor. Leads, in collaborations with the Medical Director, the EBCI Tribal Option Provider Council. Serves as the primary point of contact for the states Provider Operations Team. Develops and implements provider appeals process in accordance with

NCDHHS/EBCI

Tribal Option Contract. Fiscal and Business Management Assists with the development of analytic reports to help identify provider practice patterns that are outliers. Investigates, develops and recommends new practice models and providers for network inclusion. In collaboration with clinical, finance and quality management staff develop strategy to maximize provider performance and recommends innovative provider relationships that promote strong provider performance, pay for performance and value-based contracting. Network Functions Manages and oversees the administrative activities of Tribal Option provider contracting to include official correspondence with providers, provider education and liaison, and administration of provider contracts. In collaboration with Tribal Option Management team conducts annual evaluation of the TO Operating Plan.. Ensure health care provider have been credentialed and contracted prior to serving EBCI members. Solicits provider participation in the network and conducts re-contracting efforts as needed. Serves as a communication link between network providers and the CIHA Routinely reviews network accessibility and implements corrective action as needed. In collaboration with Member Services Manager reviews provider grievance and complaints and implement action as needed. Ensures members are informed of all significant changes within the provider network at least 30 days prior to implementation whenever possible. In collaboration with Compliance and Clinical Operations, implements procedures to ensure member continuity of care when a provider leaves or is terminated from the network. In collaboration with clinical operations coordinates provider training and ensures providers have access and are knowledgeable CIHA approved clinical guidelines. As part of the network evaluation process, establishes comparative quality reports. Supervision Received The employee exercises a moderate degree of independence; may consult with the Director of Managed Care, Assistant Director of Managed Care, Medical Director, Legal and others in resolving issues and maintaining consistency and continuity across agency operations. Personal Contacts The personal contacts are with, subordinates, co-workers, higher ranking managers, leadership of outside entities, network providers, patients, and members of the community. The purpose of the contacts are to exchange information, resolve contracting issues, improve care, and resolve differences between subordinates. Education/Experience/Minimum Qualifications Bachelor’s degree in Computer-related, Business, of Healthcare related field required. Minimum five (5) years’ experience in network operations or provider relations management preferred. Preferably, management experience in: health insurance, managed care, or IPA/PHO. Knowledge of Medicaid managed care and previous work with tribal health care is preferred. Other Requirements Strong verbal, written and interpersonal skills a must. Excellent organizational skills with strong attention to details. Proven ability to solve problems and make sound decisions. Ability to work collaboratively with cross-functional agency units and departments. Ability to work independently and within a team environment. Ability to function effectively within an ever-changing environment to meet deadlines and prioritize as necessary. Proficiency in MS Office and database tools. NC Drivers License Customer Service Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.