Job DescriptionManage and implement network compliance programs to meet all regularory, accreditation and client
standards in the assigned market – including managing the network portion around provider complaints
and grievances. It will involve presenting results of our network compliance initiatives to internal
leadership meetings and client committees. In addition, this role may also be assigned projects to
develops and promotes a positive perception of assigned business unit by cultivating a customeroriented,
collegial relationship with providers and clients. Specifically, charged with conducting effective,
clinically-substantive provider and client education and training programs for new network participants
and new client implementations, as well as when provider performance issues warrant remedial focus.
Leads in responding to and resolving provider issues; facilitates problem-solving with other internal
operations stakeholders and client provider relations staff to achieve fair and timely resolution and
positive outcomes with providers. Additionally, requires being proactive in communicating with high impact
providers in each market to ensure that the highest provider satisfaction levels are achieved and
client appreciation is gained as a result.
• Collaborates with Compliance, Quality, Legal, Account Management and Operations teams on network requirements.
• Reviews and makes recommendations on Network polices processes and policies in place to meet all standards
• Provides orientation, training, education meetings, presentations, and focus groups to improve mutual understanding and
enhance working partnerships with internal and external customers, including other departments, providers and client
• Oversees the high denial outreach/non-responder/high appeals initiative in all markets, initiating clinical education
meetings with physicians.
• Establishes and maintains optimal communication channels with client provider relations and account management,
promoting business unit`s ability to rapidly resolve provider issues.
• Collaborates with network management, corporate management, account management, operations, QI and other internal
stakeholders through internal meetings and needs analysis to develop and implement proactive provider relations
• Provides summary and problem specific feedback information, analysis, action recommendations to service center senior
management and relevant functional units regarding provider problems, issues, and general concerns impacting working
relationships and company image.
• Manages provider relation`s department day to day activities and may manage staff.
• Directs, monitors, trends, routine and long-standing provider complaints, claims, contracting, credentialing and other
problems requiring regional service center follow-up and resolution.
• Facilitates immediate resolution of red-flag provider issues that are client, community, legal, or contractual threats with
internal personnel as needed.
• Routinely monitors provider performance to target and perform remedial training sessions based upon area of need (e.g.,
authorization processes, claims submissions, etc.
• 7+ years of experience in a Provider Relations role for a managed care plan.
• 2+ years’ experience or demonstrated knowledge of network regulatory requirements and network management to those
• Project Management experience preferred.
• Solid knowledge of health plan operations required.
General Job Information
TitleSenior Provider Relations Manager
Job FamilyOperations Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date3/22/2019
Date Requisition Created3/22/2019
EducationBachelors (Required), Masters
License and Certifications - Required
License and Certifications - Preferred
Other Job Requirements
- 7+ years of experience in a Provider Relations role for a managed care plan.
- 2+ years’ experience or demonstrated knowledge of network regulatory requirements and network management to those requirments.
- Project Management experience preferred.
- Solid knowledge of health plan operations required.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.