Access to Care Program Manager

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PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Access to Care Program Manager will oversee and manage all aspects of provider network access for all assigned networks. Responsibilities include development, management and oversight of access to care plans for each network. Manages regular and ad hoc network evaluation and reporting to state agencies. Responsibilities also include engaging, informing, and responding to internal stakeholders and state agencies.

Essential Responsibilities:

• Manages network access monitoring and reporting to State and/or Federal agencies, including leading report writing and project management . Collaborates closely with and monitors access functions across Provider Network teams, project managers, and cross-departmental subject matter experts.
• Establishes tools and processes necessary to meet all State and Federal reporting and monitoring requirements.
• Maintains full understanding of current State and Federal regulatory requirements related to network management, reporting and provider directory accuracy.
• In consultation with company experts, interprets regulatory requirements for network access and adequacy for cross functional teams.
• Maintains and updates required documentation and policies related to network access and adequacy regulations.
• Responds to regulator inquiries or objections by researching the objection, including the laws cited. Works with a cross functional team to compose and deliver a response.
• Reviews network access reports to create trend analyses and summaries for decision-making purposes including disruption analysis for PacificSource markets and networks. Assimilates large quantities of simple and moderately complex data into meaningful formats for tracking and status inquires.
• In collaboration with various Provider Network teams and other experts, ensures the accuracy and quality of data related to provider network access and adequacy reporting.
• Interprets and consults on access analyses for Provider Contracting and other company stakeholders, in collaboration with analyst teams.
• Monitors State and Federal sanctions/corrective actions against other payers to ensure PacificSource avoids similar disapproved practices.
• Monitors contract requirements for adherence to components, tracks and manages deliverables, establishes improvement plans as needed.
• Collaborates with PacificSource filing teams and content leaders for forms, rates and binders to ensure annual network reports align with those filings.
• Collaborates with Analytic teams to perform analytical reviews and evaluations of healthcare provider networks by analyzing data, contributing to the development of data models, and using business analytical tools to produce data visualizations.
• Develops reports to make recommendations for management consideration regarding issues of potential healthcare provider network access gaps identified through analysis, internal referrals, healthcare providers, and member complaints.
• Creates reports for internal stakeholders, advising of potential and actual access issues. Tracks progress toward resolution.
• Collaborates with reporting team to develop optimal formats, review for quality and accuracy, and communicate both scheduled and ad hoc requests.
• Communicates directly with State agencies or PacificSource’s internal government relationship owner on Access topics and filings, with direction and guidance of leadership.
• Monitors tracking tools for network adequacy for assigned lines of business, being able to easily show status of contracting efforts/success in obtaining adequate and marketable network.
• Updates Policies and Procedures related to Access reporting and monitoring requirements.
• Leads access to care cross-departmental Access to Care Committee for assigned networks to develop comprehensive regional work plans and mitigation strategies based on regulatory requirements.
• Collaborates to develop and implement Provider Network-focused health equity initiatives aligned with provider workforce development, the health equity Quality Incentive Measure (QIM), and other internal priorities.
• May submit required provider contract or regulatory filings to State agencies per assigned network regulatory requirements, with direction and guidance of leadership.

Supporting Responsibilities:

• Facilitates and actively participates in Access to Care Workgroups.
• Meets department and company performance and attendance expectations.
• Follows the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Performs other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of 5 years of experience in healthcare, managed care, public health or community-based organizations. Experience with government-funded health care programs (Medicaid and Medicare) and managed care health plans strongly preferred for success in this role. Experience directly working with Insurance Commissioner Offices is desired.

Education, Certificates, Licenses: Bachelor’s degree required. Preferred areas of focus: healthcare administration, business, clinical degree, or related. Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered. Master’s degree preferred.

Knowledge: Demonstrated ability using sound professional judgment to determine cadence and content of regulatory reporting and interaction. Advanced analytical, problem-solving skills, and technical writing skills required. Experience with carrying out systems for monitoring health care organization performance with regulations, requirements, and contract stipulations. Experience designing and implementing quality improvement and/or corrective action performance improvement plans or initiatives. Excellent public relations, presentation, and interpersonal skills required. Demonstrated successful communication skills, including public presentation, training, meeting facilitation and collaboration. Demonstrated experience leading and contributing to cross functional teams to initiate and manage work. Problem solve, develop and execute plans, and complete work requirements. Maintain high-level of knowledge of regulatory requirements, company products, health reform trends at the Federal and State levels, and the insurance industry. Math skills required including percentages, ratios, graphing. Demonstrated skills with the following software: Microsoft Word, PowerPoint, Excel.

Competencies

Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately up to 10% of the time.

Skills:

Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:

$72,443.87 - $126,776.77

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.

• We are one team working toward a common goal.

• We are each responsible for customer service.

• We practice open communication at all levels of the company to foster individual, team and company growth.

• We actively participate in efforts to improve our many communities-internally and externally.

• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.