Director, Provider Network Operations

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Residency in or relocation to Louisiana is preferred for all positions.

This position is flexible in office.

POSITION PURPOSE

This position is accountable for the strategic direction and management of the Provider Network Operations staff, which supports all provider network operational activities and ensures compliance with standards for network participation, state and federal regulatory requirements, and accrediting entity standards.

NATURE AND SCOPE

• Manages People
• This role directly manages 5 workers
• This role directly manages these jobs: Manager, Provider Contract Administration;Manager, Provider Data Integrity;Manager, Provider Information;Provider Operations Program Manager
• This role indirectly manages 30 workers
• This role reports to this job: VP, Health Services Systems and Support
• Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with: Provider Network Operations Systems, Benefits Operations, Provider Contracting, HQM, Marketing, Legal, IT, Provider Reimbursement, Business Engineering, Medical Management, Value Based Operations, Vantage, and all levels of company employees to assist with the provider network and reimbursement management in the provider database. External contacts including providers, billing agencies, provider licensing and accreditation organizations, and state agencies, such as Department of Insurance and business consultants, Blue Cross Blue Shield Association, and industry contacts.
  
  

Qualifications

Education

• Bachelor's degree in business or a related field is required.
• Master's degree in a related field preferred.
• Four years of related experience can be used in lieu of a Bachelor’s degree.
  
  

Work Experience

• 7 years of experience in business operations, including analyzing policies and procedures, maintaining performance metrics, improving operational processes, and providing proactive solutions related to process improvement and system implementations required
• 3 years of progressive leadership experience, including direct supervision of staff required
• Vast experience effectively leading and working with multidisciplinary teams
• Experience leading the implementation of complex organizational change
• Experience can run concurrently
  
  

Skills And Abilities

• Working knowledge of Microsoft Office Software (e.g. Word, Excel, etc.), other related departmental software and system capabilities
• Ability to build constructive, trusting relationships and bring others together across the organization to achieve major goals that align with strategy
• Demonstrated ability to work in a fast-paced culture with proven ability to build, develop, and lead strong teams
• Demonstrated ability to lead, organize and prioritize an operations team and multiple initiatives and projects, with the ability to drive the standardization and operationalization of processes while ensuring quality
• Professional demeanor with excellent oral and written communication skills with close attention to detail as required due to the high amount of direct customer/provider contact and the need to continually communicate with both internal and external customers and internal support staff
• Excellent analytical and troubleshooting skills, with the ability to proactively resolve problems
• Ability to judge severity of problems and use discretion in obtaining services or escalating to senior management as needed
• Possess a can-do attitude and stamina for tackling hard problems
  
  

Licenses and Certifications

• Health insurance industry certifications preferred
• Lean Six Sigma training strongly preferred
  
  

Accountabilities And Essential Functions

• Manages supervisory and staff level positions by administering all HR functions, including but not limited to, hiring, terminating, conducting performance reviews, managing work schedules, managing a budget, assigning and directing workload, training and developing staff, coaching, monitoring and managing work inventories, etc. to help ensure departmental, divisional and/or corporate goals are met.
• Ensures compliance with standards for network participation, state and federal regulatory requirements, and accrediting entity standards.
• Directs the continual development, technological improvement and progression of provider operational functions related to provider onboarding and provider network operations, including contract management, provider data management, directory file maintenance and enhancement, reimbursement maintenance for professional providers, provider credentialing and re-credentialing, network participation setup, data accuracy, credentialing delegation oversight, and management reporting.
• Partners with leaders in Provider Systems, IT, and other business areas to develop and execute against a technology roadmap
• Develops and maintains a core set of operational analytic reporting to determine and manage the overall efficiency and effectiveness of the department and workload of the operations, leading through metrics and high standards.
• Ensures successful execution of assigned projects, initiatives, goals, and objectives consistent with the corporate strategic plan, state and federal laws and divisional goals through managing, training, and coordinating the Provider Operations staff.
• Understands requirements and ensures compliance with applicable state and federal regulatory requirements (including CAA), BCBSA requirements, BCBSLA requirements, and accreditation standards as related to provider data management.
• Maintains thorough understanding of Plan’s credentialing standards for provider data management and ensures departmental compliance.
• Directs and supports the Plan’s provider credentialing function and ensures the credentialing processes and procedures support the requirements for network accreditation as established by URAC, NCQA, or other accreditation organizations to reduce the Plan’s exposure to liability and the Plan’s subscriber base from the negligence of providers.
• Directs the entire provider contract cycle and works closely with Legal, other internal departments, and providers on standard and non-standard contract language, as well as ensuring that contracted networks and reimbursement agreements are properly set up for the providers.
• Directs the operations of the Provider Contract Administration functions, ensuring compliance with Plan’s corporate policies and requirements for managing Provider Contracts
• Identifies process gaps and supports continuous process improvement to improve efficiency and effectiveness of staff and operations, enabling a positive provider and customer experience. Applies an enterprise approach to opportunities while driving value.
• Partners with Provider Relations and Communications to inform and support provider education needs to improve the overall service delivery to providers.
• Supports the OptiNet program and all Blue Cross Blue Shield Association mandates and changes.
• Conducts other duties as required.
• Accountable for complying with all laws and regulations that are associated with duties and responsibilities.
  
  

Additional Accountabilities And Essential Functions

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.
  
  

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An Equal Opportunity Employer

All BCBSLA EMPLOYEES please apply through Workday Careers.

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Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.

In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.

JOB CATEGORY: Insurance