We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate. We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways.

At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters. Come make a difference at Ochsner Health and discover your future today!

This job leads and manages the provider relations function, provider data management, delegation oversight of vendors and network management function within Ochsner Health Plan (OHP) in accordance with established plans, standard operating procedures, and legal and regulatory requirements. Ensures ongoing network development and available capacity to the membership of OHP with a commitment to overall OHP network adequacy. Collaborates with the leadership team to inform strategy and ensure the operational effectiveness, financial success, and ongoing implementation of strategic goals and priorities. Develops, implements, and monitors policies and procedures, executes on-going network development to prevent network deficiencies and meet or exceed budgeted costs, oversees the onboarding of providers to include contracting and negotiating rates, applies corrective action plan for provider contract deficiencies and recommends liquidated damages if necessary, and assumes primary responsibility and leadership for the function.

Education
Required - Bachelor's degree in business or healthcare administration.
Preferred - Master's degree.

Work Experience
Required - 7 years of experience with progressive responsibility in a leadership role within a provider relation function.
5 years of experience working within a health plan (commercial and/or government), with experience in a mature managed care market characterized by a delegated model, and capitated or other risk sharing contracts.
Preferred - 10 years of experience working with Medicare Advantage Health Plans, provider data accuracy, and CMS network requirements, including writing network exceptions.

Knowledge Skills and Abilities (KSAs)

• Proficiency in using computers, software, and web-based applications.
• Effective verbal and written communication skills and ability to present information clearly and professionally.
• Strong interpersonal skills.
• Knowledge of Provider claims issue resolution.
• Knowledge of provider data management and oversight.
• Knowledge of third-party risk strategic concepts, applicable laws and regulations, business risk, effective risk management techniques and auditing.
• Advanced organizational skills and ability to manage multiple projects and work under pressure with tight deadlines.
• Strong analytical and operational problem-solving skills and ability to be self-directed.

Job Duties

• Plans overall OHP provider relations/network management strategy.
• Leads Manager, Provider Data Integrity role
• Oversees management of provider data through a vendor relationship.
• Supports network and product expansion by identifying targeted provider recruitment.
• Manages delegation oversight for vendors supporting credentialing function.
• Manages relationship with Quest Analytics for directories, HSD tables, accuracy, and adequacy of provider data.
• Works with other health plan departments to ensure correct configuration of providers and fee schedules.
• Supports Provider Relations team to resolve provider claims issues.
• Creates and reviews monthly reports, conducts quarterly reviews, and creates supplemental action programs.
• Performs other related duties as assigned.

The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.

Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.

This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns. The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.

Physical and Environmental Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Sedentary Work - Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid.
The incumbent has no occupational risk for exposure to communicable diseases.

Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and/or disposal of contaminated waste. The risk level of exposure may

Are you ready to make a difference? Apply Today!

Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website.

Individuals who reside in and will work from the state of Colorado are not eligible for remote work position .

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