Network Relations Manager

3 weeks ago

Orange, California, United States Regal Medical Group Full time
Job Summary:

We are seeking a skilled Network Relations Manager to join our team at Regal Medical Group. As a key member of our organization, you will be responsible for managing our provider network, ensuring smooth operations, and driving growth and development initiatives.

Key Responsibilities:

Collaborate with the Director of Network Management and Medical Management team to achieve network growth and development goals.
Prepare and negotiate provider contractual agreements during recruitment projects.
Conduct new provider and staff orientations, and provide ongoing education to ensure effective communication and utilization of company programs and tools.
Oversee assigned networks, ensuring provider deficiencies are met, and working closely with Network Support staff and Medical Management counterparts to address network needs and changes.
Maintain and update databases and department tools with current information.
Coordinate, review, and process provider contracts, credentialing, and correspondence to ensure proper signatures and documentation.
Complete PACFs related to incoming documentation from providers, ensuring timely and accurate completion.
Submit provider profiles to health plans, conduct follow-up to ensure Primary Care Physicians are active, and obtain health plan-assigned provider identification numbers.
Ensure terminated PCPs are effectively terminated and enrollment retention efforts are followed.
Review health plan directories for assigned networks and communicate adds/terminations/changes to the health plan.
Assist with resolving provider grievances and appeals in accordance with contractual requirements and corporate policy.
Interact daily with regional providers and conduct quarterly visits to PCP and Specialist offices.
Ensure contract compliance and adherence to DMHC, DHS, CMS, and other regulatory agencies as required by company policy and contracting HMOs.
Serve as an internal network liaison for Database, Claims, Customer Service, Medical Management, and Quality Management Departments.
Perform on-site visits to physicians, physician groups, hospitals, and ancillary providers.
Facilitate quarterly Joint Operations Meetings with contracted providers and office staff.
Oversee database maintenance and accuracy through audits.
Ensure accurate and timely data reporting requirements are met, including eligibility and capitation reports, risk sharing, claims timeliness, pharmacy utilization, bed days utilization, encounter data, and audit compliance.
Maintain patient confidentiality and adhere to HIPAA compliance at all times.

Requirements:

Minimum 3 years of relevant work experience in Network Management, Contracting, or Provider Relations in a managed care setting, health plan, or large medical group administration.
Knowledge of contracting principles and tools.
Excellent verbal and written communication skills.
Proficient in MS Office programs (Word, Excel, Outlook, Access, and PowerPoint).
Ability to travel within the service area 70-80% of the time and have a valid driver's license and insurance.

What We Offer:

Regal Medical Group offers a comprehensive benefits package, including employer-paid comprehensive medical, pharmacy, and dental, vision insurance, flexible spending account, employer-paid life insurance, employee assistance program, behavioral health services, 401(k) retirement savings plan, income protection insurance, tuition reimbursement, license renewal CEU cost reimbursement program, business-casual working environment, sick days, paid holidays, mileage, and more.

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