Manager of Provider Relations

Industry: Education, Government & Non-Profit


5 - 7 years

Posted 81 days ago

This job is no longer available.


This position is responsible for the management and oversight of provider relations, provider communications and claim edit and payment policy. This position develops, implements and oversees strategies and policies and procedures for building collaborative relationships with providers through provider education, training and service recovery, regulatory requirements, operations and communication in support of strategic and corporate goals. This position is externally facing and will provide support in the absence of a director.


  • Manage, direct and mentor staff
  • Develop and implement educational processes and pro-active solutions for payment and other provider operations requirements
  • Develop and establish guidelines and measures for provider relations, provider communications and claim edits and payment policies that align with corporate goals and measures
  • Develop and manage provider servicing strategies to ensure collaborative relationships with providers are built and sustained
  • Direct the planning, development and implementation of ongoing communication programs and initiatives for the provider network
  • Responsible for maintaining provider network adequacy standards
  • Ability to work independently/without direct supervision
  • Monitor, evaluate and routinely report on the performance of providers against goals and targets
  • Develop, implement and maintain strategies supporting provider satisfaction
  • Identify performance issues including policy and procedures, processes, workflows, communication and trends and recommend and implement strategies to address
  • Ensure timely and accurate submission of required regulatory reports to state and federal agencies
  • Collaborate and consult with internal leaders and departments to coordinate relevant cross functional activities in support of network performance management efforts to maximize the organization’s competitive position
  • Collaborate with internal leaders to develop strategies and actions to improve provider group/network performance, as needed
  • Manage provider relations, communication claim edits and payment policy staff to ensure job functions are completed appropriately and according to priorities.
  • Develop employee performance plans, conducts formal performance appraisals and takes appropriate disciplinary action in accordance with Human Resources policies and procedures. Provides individualized coaching and feedback on a consistent basis to ensure maximum performance potential. Responsible for the hiring and training process including recommendations regarding staff retention and termination and succession planning
  • Assist in the development of operating and capital budget for the department
  • Represent the company in internal and external committees and meetings
  • Prioritize and organize all work to meet deadlines
  • Responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
  • Other duties as assigned



  • Demonstrated working knowledge of the health care industry and its impact on providers
  • Excellent quantitative and analytic skills with ability to synthesize complex information to create and evaluate options
  • Energetic, goal driven leader with a proven ability to deliver bottom line results who can motivate and mobilize staff to achieve goals. A strategic thinker who can assess implications and formulate plans for action.
  • Excellent interpersonal communications skills and a high level of diplomacy to anticipate, recognize and address effectively with politically sensitive issues
  • Strong relationship building skills to influence and work collaboratively with physicians, hospitals, business leaders and internal departments
  • High degree of business and financial acumen to manage external delivery system costs and implement strategies that promote and sustain enrollment growth
  • Proven ability to balance execution of the strategic vision through leadership and delegation with a willingness to dive into the details as required
  • Demonstrated interpersonal skills (including writing and verbal communication skills) to interact effectively with a diverse range of internal and external constituents, stakeholders, and audiences. Willingness to challenge the status quo to implement creative strategies in a solidly matrixed, complex organizational environment.
  • Ability to manage multiple projects simultaneously
  • Resilient, collaborative, flexible, innovative
  • Five (5)+ years’ experience with a managed care organization or a health care related organization (HMO; Medicaid, Medicare)
  • Five (5)+ years’ experience with commercial, Medicaid or Medicare provider relations, communication, policies or related experience
  • Three (3)+ years’ experience managing staff including ability to lead, motivate, and develop staff, with effective interpersonal and conflict resolution skills
  • Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
  • Bachelor’s degree in Health Administration, Business Administration, Public Health, Communications or a related field or an equivalent amount of education and experience


  • Experience in Project Management
  • Experience in Cognos
  • Experience in MedInsight
  • Experience in SharePoint
  • Knowledge of Quality Improvement Processes (e.g. Lean, Six Sigma)
  • Master’s degree in Health Care Administration, Business Administration, Communications or Public Health or a related field

Organizational Competencies:

  • Judgment and Decision Making
  • Gets Results
  • Collaboration and Teamwork
  • Business Awareness
  • Customer Focus

Job Specific Competencies:

  • Problem Solving/Analysis
  • Planning & Organizing
  • Open Communication
  • Relationship Building & Networking
  • Flexibility & Achieving Change

Travel Expectations:

  • Ability to travel including reliable transportation, a valid driver’s license and proof of insurance.