Provider/Vendor Relationship Manager - Medicaid

Job Description

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy.

AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

PURPOSE OF THE JOB

Manages vendor clinical and non-clinical programs, tracks interventions, programs outcomes and services to facilitate the achievement and value of Medicaid Segment goals.

Performs ongoing program management and coordination internally and externally to ensure that vendors meet or exceed their contractual obligations by delivering quality outsourced services.

Contributes to the efficiency, productivity and success of the organization.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

1. Required Work Experience

5 years of business operational experience including program implementation, operational solutions and working

collaboratively with other departments and different levels of administration or equivalent

• 5 years of health plan experience or equivalent
• 2 years relevant program management experience
• 3 years of experience in designing, implementing and / or managing large complex outsource programs or equivalent

2. Required Education

High-School Diploma or GED in general field of study

3. Required Licenses

N / A

PREFERRED QUALIFICATIONS

1. Preferred Education

Master’s degree in healthcare administration, business administration, law, public health, nursing, social work or related

field

2. Preferred Licenses

N / A

3. Preferred Certifications

Six Sigma Green Belt Certification

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Function as the primary contact with assigned vendor partner(s) and internally, and provide in-depth insight into all program and process components
• Coordinate all internal and external communication and processes for the vendor arrangement including but not limited to claims processing, audits, file transfers, utilization management (including appeals), network management, credentialing, enrollment, member relations, sales, marketing, reporting, information technology, etc.
• Select and work with a team of internal subject matter experts to implement new services / processes or resolve issues
• Schedule, plan and document all ad hoc and routine vendor / internal operational meetings
• Timely and accurate creation of minutes, issues logs, workflows, policy, procedures, performance tracking, reporting, etc.

for the vendor relationship and associated internal procedures and processes

• Maintain all program documentation per department guidelines; manage shared drive documentation; review and revise as applicable
• Review vendor policy, procedures and processes as applicable
• Ensure vendor is in compliance with BCBSA, BCBSAZ, AHCCCS, CMS, and NCQA guidelines and regulations
• Facilitate updating of correspondence for branding, health literacy, non-discrimination, or other regulatory requirements
• Conduct training regarding the outsourced program
• Review complaints and quality metrics
• Facilitate a clinical review of applicable clinical program components
• Monitor performance guarantees and key internal and external metrics; timely escalation of negative findings to leadership;

and coordinate both internal and external for corrective action / resolution

Coordination of the delegation oversight as applicable for Utilization Management, Case Management, Network Management, Member Relations, Credentialing or other;

follow-up with subject matter experts as needed; maintain applicable accreditation compliance

Track and initiate key processes for timely contract negotiation; facilitate the planning and negotiation of contracts;

communicate finalized contractual components to vendor and operational areas as applicable

• Prepare presentation to delegation committee, quality committee and executive leadership on vendor performance
• Timely and accurate responses to internal and external questions or concerns regarding the vendor program,
• Proactive identification, reporting and coordination of resolution to reduce program risk; timely escalation of known issues to leadership
• Monitor vendor performance trends to ensure attainment of customer experience and performance goals
• Motivate internal and external teams to promote collaboration to strengthen and unify the entire supporting team
• Provide communication and follow up to ensure resource planners are fully informed of all information needed to implement or maintain the program per the contractual arrangement, both internally and with the vendor
• Improve overall quality of the program by identifying target opportunities and executing on improvement with the vendor and internal staff;

analyze data; and perform root cause analysis to identify potential issues

• Provide RFI / RFQ feedback and responses
• Coordinate with BCBSAZ Procurement and Legal on vendor contracts, statements of work, service level agreements and related documents.
• Oversees day-to-day vendor management processes and works as a liason between between Procurement and business owners
• Assesses the overall performance of vendor programs and makes strategic recommendations for improvements.
• Leads and engages key stakeholders with the delivery and execution of the Medicaid Segment programs across to ensure program interventions, goals and targeted outcomes are integrated with systems / processes and in alignment with strategic initiatives.
• Provide education and training on the Medicaid Segement vendor programs to internal staff and others as appropriate
• Coordinate with Finance and business owners on vendor contract payment terms and provide oversight to the review, reconciliation, approval and payment of vendor invoices, including applying vendor credits / penalties when necessary.

Manage outsource spend against spend objectives and targets. Write RFI’s / RFP’s and coordinate the request for information / proposal development cycle

Responsible for staying abreast of product / member / provider issues, legislation, mandates, policy changes and system changes as applicable to the vendor processes.

Keep vendors informed on developments in the organization or market conditions that may affect demand or process changes for vendors’ services.

• Interim resource for higher-level issues in manager absence.
• Collaborate with business partners to define and negotiate business terms in vendor agreements.
• Collaborates with manager and team in standardized and policies and procedures to be used by the department.
• Collaborate with team members to ensure : Vendor performance scorecards are maintained for each of the vendors

Vendor relationship issues are addressed and resolved timely

Vendor accountability for performance improvement and solving issues, to include corrective actions that are timely and effective.

Audits are performed as required

• Work with Manager on activities related to the planning and implementation or expansion of outsourced functions.
• Alerts Manager of concerns related to any of the above items.
• Collaborate and identify with manager quantifiable / measurable departmental goals
• Utilize project management and six sigma techniques
• Demonstrate and maintain current working knowledge of the required BCBSAZ systems, procedures, forms and manuals
• Meet deadlines in required timeframe established by management
• Coordinate with Corporate Integrity and Information Security Services on risk identification and mitigation related to items such as privacy, security and business continuity related to outsourced services.

Coordinate assessment of vendor practices to assure ongoing compliance with requirements.

• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned.

COMPETENCIES

REQUIRED COMPETENCIES

1. Required Job Skills

• Strong oral and written communication skills
• Ability to coordinate with stakeholders across the company and manage occasionally competing interests.
• Proficiency in planning and project coordination / management.
• Experience with giving presentations; educational sessions
• Effective organizational skills and attention to detail.
• Knowledge of healthcare industry.
• Proficiency in spreadsheet, database, flowcharts and diagrams, and word processing software.
• Ability to understand the workflow of multiple components of the company and to assist in the creation and implementation of integrated policies, procedures, workplans and creative solutions.
• Ability to gather, analyze data and prepare informative and accurate reports.

2. Required Professional Competencies

• Strong customer relationship management skills, both external and internal.
• Strong skills in influence, persuasion, negotiation and problem resolution.
• Ability to create win / win situations with vendor partners and internal operations management.
• Strong analytical skills. Ability to use data to recommend operational decisions and drive improvement along with organizational skills to analyze, interpret data, synthesize, evaluate and explain educational concepts, practices and methodologies to staff and transfer data to and from written and verbal medium
• Strong experience with performance management, contract management and financial management
• Self motivated and demonstrated initiative with independent, sound judgment and good problem solving skills
• Establish and maintain working relationships in a collaborative team environment
• Ability to develop, organize, motivate, coordinate and collaborate effectively with stakeholders from multiple business areas across the organization 3.

Required Leadership Experience and Competencies

• Ability to provide guidance and support to team members
• Ability to build strong relationships with team members and business areas
• Maintain effective working relationships to ensure teamwork in achieving company goals
• Effective interpersonal skills and ability to maintain positive working relationships with others.
• Experience leading and implementing projects and working collaboratively with other departments and levels of administration
• Strong organizational and management skills
• Ability to apply sound management decision making skills to perform effectively in the absence of management
• Ability to effectively deal with conflict

PREFERRED COMPETENCIES

1. Preferred Job Skills

• Strong vendor management skills.
• Knowledge of internal controls, risk assessment and vendor due diligence.
• In-depth understanding of technical capabilities.
• Knowledge of Six Sigma techniques
• In-depth understanding of project management techniques
• Advanced proficiency in spreadsheet, database, flowcharts and diagrams, and word processing software.
• Knowledge of accreditation requirements.
• Knowledge of writing RFI / RFP’s and coordinating the proposal development cycle

2. Preferred Professional Competencies

• Demonstrated understanding of outsourcing business strategies and best practices; financial acumen.
• Thorough knowledge of the company’s needs, policies and culture.
• Understands the nuances of contracts and holding vendors accountable to turn around problem relationships.

3. Preferred Leadership Experience and Competencies

• Knowledge of leading and motivating teams for peak performance
• Ability to build strong relationships and influence team members in establishing succesful work relationships
30+ days ago