12 Provider Quality jobs in the United States

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.
**_Candidates must reside in Reno or preferably Elko, Nevada due to travel requirements of up to 50% to local provider offices and member locations._**
**_Ideal candidates will have:_**
+ **_Experience with Quality/HEDIS measures_**
+ **_Strong communication skills with comfort speaking to members_**
+ **_Proficiency in Excel, Word, and Adobe is a plus_**
**Position Purpose:**
Responsible for connecting with plan providers regarding quality initiatives and key quality performance indicators. Shares HEDIS, CAHPS, HOS, Part D and Administrative Operations reports and gap lists with providers. Use existing resources to collaborate with provider offices and internal partners on performance measure barriers, actions to mitigate low performing measures, and the sharing of quality best practices to support providers.
+ References and connects providers with existing resources to educate provider practices in appropriate HEDIS (Healthcare Effectiveness Data and Information Set) measures, medical record documentation guidelines and Member Experience measures.
+ Acts as an ongoing resource to providers for quality improvement via regular touch points and meetings.
+ Educates, supports, and resolves provider practice sites issues around P4P (Pay for Performance), RxEffect, CAHPS (Consumer Assessment of Healthcare Providers and Systems), HOS (Health Outcomes Survey), CTMs (Complaints to Medicare), Disenrollment's, Appeals, and Grievances.
+ Collaborates with Provider Relations and other provider facing teams to improve provider performance in Quality (Clinical and Member Experience measures). Provides clear insight into provider group dynamics, identifies areas of opportunity, builds action plan and collaborates cross functionally to support quality performance.
+ Develops, enhances and maintains provider relationship across all product lines (Medicare, Medicaid, Ambetter). Supports the development and implementation of quality improvement interventions in relation to Plan providers
+ Conducts telephonic outreach to members to encourage members to visit the physician in an effort to close quality care gaps.
+ Performs other duties as assigned.
+ Complies with all policies and standards
**Education/Experience:**
High school diploma or equivalent. Associate's degree preferred. 2+ years of experience with clinical and member experience quality.
**License/Certification:** Driver's License required. Pharmacy Technician, Medical Assistant Licensed Vocational Nurse, Licensed Practical Nurse, Social Work licensure preferred.
Pay Range: $19.04 - $32.35 per hour
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

**Title:** Behavioral Health Provider Quality Manager
**Candidates must posses a licensure for the state of California.**
**Location:** This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered.
**This position will be required to travel out to the field as needed in** **Northern California.**
**Schedule:** Pacific Standard Time
Carelon Health is a proud member of the Elevance Health family of brands, offering clinical programs and primary care options for seniors. We are a team of committed clinicians and business leaders passionate about transforming American healthcare delivery.
The **Provider Quality Manager** is responsible for leading Behavioral Health (BH) provider engagement, with a focus on leveraging the data available to providers and helping to improve the value delivered to Carelon members. Drives BH provider performance improvement year over year through education and data. This role is responsible for a local market.
**How will you make an impact:**
+ Establishes relationships and engages with BH providers and ensures measurable improvements in clinical and quality outcomes for members.
+ Builds relationships with internal clinical and quality departments to ensure high-quality care to members and achievement of company HEDIS performance. Implements strategies that meet clinical, quality, and network improvement goals.
+ Build positive working relationships with providers, state agencies, advocacy groups, and other market stakeholders.
+ Meets routinely with strategic providers face to face, telephonically, and via Web-Ex to support provider training on Carelon processes, contracting / credentialing and linkages for issue resolution, helping to improve provider experience and overall satisfaction with Carelon.
+ Acts as a liaison between strategic providers and Carelon clinical, quality, provider strategy, operations, and claims, to ensure interdepartmental collaboration and coordination of goals and priorities.
+ Supports regional and corporate initiatives regarding Carelon Select Provider (CSP) program, clinical innovation, and thought leadership transforming provider relationships from transactional interactions to collaboration.
+ Creates and maintains linkages between providers of all levels of care, as well as other community-based services and resources to improve transitions of care and continuity of services.
+ Partners with network providers and Carelon stakeholders to operationalize innovative programs and online resources to improve clinical and quality outcomes.
+ Analyzes provider reports pertaining to cost, utilization, and outcomes, and presents the data to providers and highlights trends.
+ Identifies data outliers and opportunities for improvement for individual providers.
+ Identifies high-performing and innovative providers who may be interested in new programmatic incentives or payment models.
+ Participates in the identification of opportunities for expansion and development of innovative pilot programs, implementation, launch, and efficacy and outcomes measurements.
+ Contributes to the identification of high-quality program ideas/designs into the local market to drive high levels of value.
+ Provides consultation to providers for clinically complex members as applicable.
+ Surfaces clinical and quality issues to regional clinical and quality teams and participates in helping to address concerns.
+ Conducts quarterly physician record reviews or as needed with network providers across all service levels.
+ Assists with provider orientations and provider training events in the region, when applicable.
+ Attends all accessible County BH provider meetings either in person or via telephone or Web-ex.
**Minimum requirements:**
+ Requires MA/MS or above in Behavioral Health field and a minimum of 10 years of progressively responsible professional experience in healthcare which includes a minimum of 5 years' experience in a behavioral health setting, either provider or payer; or any combination of education and experience, which would provide an equivalent background.
+ Current, valid, independent, and unrestricted license such as RN, LCSW, LMFT, LMHC, LPC, or Licensed Psychologist (as allowed by applicable by state laws) is required.
**Preferred Skills, Capabilities, and Experiences:**
+ Candidates who reside in Northern California HIGHLY preferred
+ Behavioral Health experience preferred.
+ Travels to the worksite and other locations as necessary preferred.
+ Managed care experience preferred.
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $90,240 - $135,360.
Location: California
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

**Title:** Behavioral Health Provider Quality Manager
**Candidates must posses a licensure for the state of California.**
**This position will be required to travel out to the field as needed in** **Northern California.**
**Location:** This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
_Alternate locations may be considered if candidates reside within a commuting distance from an office_ _Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law._
**Schedule:** Pacific Standard Time
Carelon Health is a proud member of the Elevance Health family of brands, offering clinical programs and primary care options for seniors. We are a team of committed clinicians and business leaders passionate about transforming American healthcare delivery.
The **Provider Quality Manager** is responsible for leading Behavioral Health (BH) provider engagement, with a focus on leveraging the data available to providers and helping to improve the value delivered to Carelon members. Drives BH provider performance improvement year over year through education and data. This role is responsible for a local market.
**How will you make an impact:**
+ Establishes relationships and engages with BH providers and ensures measurable improvements in clinical and quality outcomes for members.
+ Builds relationships with internal clinical and quality departments to ensure high-quality care to members and achievement of company HEDIS performance. Implements strategies that meet clinical, quality, and network improvement goals.
+ Build positive working relationships with providers, state agencies, advocacy groups, and other market stakeholders.
+ Meets routinely with strategic providers face to face, telephonically, and via Web-Ex to support provider training on Carelon processes, contracting / credentialing and linkages for issue resolution, helping to improve provider experience and overall satisfaction with Carelon.
+ Acts as a liaison between strategic providers and Carelon clinical, quality, provider strategy, operations, and claims, to ensure interdepartmental collaboration and coordination of goals and priorities.
+ Supports regional and corporate initiatives regarding Carelon Select Provider (CSP) program, clinical innovation, and thought leadership transforming provider relationships from transactional interactions to collaboration.
+ Creates and maintains linkages between providers of all levels of care, as well as other community-based services and resources to improve transitions of care and continuity of services.
+ Partners with network providers and Carelon stakeholders to operationalize innovative programs and online resources to improve clinical and quality outcomes.
+ Analyzes provider reports pertaining to cost, utilization, and outcomes, and presents the data to providers and highlights trends.
+ Identifies data outliers and opportunities for improvement for individual providers.
+ Identifies high-performing and innovative providers who may be interested in new programmatic incentives or payment models.
+ Participates in the identification of opportunities for expansion and development of innovative pilot programs, implementation, launch, and efficacy and outcomes measurements.
+ Contributes to the identification of high-quality program ideas/designs into the local market to drive high levels of value.
+ Provides consultation to providers for clinically complex members as applicable.
+ Surfaces clinical and quality issues to regional clinical and quality teams and participates in helping to address concerns.
+ Conducts quarterly physician record reviews or as needed with network providers across all service levels.
+ Assists with provider orientations and provider training events in the region, when applicable.
+ Attends all accessible County BH provider meetings either in person or via telephone or Web-ex.
**Minimum requirements:**
+ Requires MA/MS or above in Behavioral Health field and a minimum of 10 years of progressively responsible professional experience in healthcare which includes a minimum of 5 years' experience in a behavioral health setting, either provider or payer; or any combination of education and experience, which would provide an equivalent background.
+ Current, valid, independent, and unrestricted license such as RN, LCSW, LMFT, LMHC, LPC, or Licensed Psychologist (as allowed by applicable by state laws) is required.
**Preferred Skills, Capabilities, and Experiences:**
+ Candidates who reside in Northern California HIGHLY preferred
+ Behavioral Health experience preferred.
+ Travels to the worksite and other locations as necessary preferred.
+ Managed care experience preferred.
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $90,240 - $135,360.
Location: California
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Behavioral Health Provider Quality Manager
**Candidates must posses a licensure for the state of California.**
**Location:** This role requires associates to be in-office **1** day per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.
_Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law._
**Schedule:** Pacific Standard Time
This position may be required to travel out to the field as needed.
**Build the Possibilities. Make an Extraordinary Impact.**
Carelon Health is a proud member of the Elevance Health family of brands, offering clinical programs and primary care options for seniors. We are a team of committed clinicians and business leaders passionate about transforming American healthcare delivery.
The **Provider Quality Manager** is responsible for leading Behavioral Health (BH) provider engagement, with a focus on leveraging the data available to providers and helping to improve the value delivered to Carelon members. Drives BH provider performance improvement year over year through education and data. This role is responsible for a local market.
**How will you make an impact:**
+ Establishes relationships and engages with BH providers and ensures measurable improvements in clinical and quality outcomes for members.
+ Builds relationships with internal clinical and quality departments to ensure high-quality care to members and achievement of company HEDIS performance. Implements strategies that meet clinical, quality, and network improvement goals.
+ Build positive working relationships with providers, state agencies, advocacy groups, and other market stakeholders.
+ Meets routinely with strategic providers face to face, telephonically, and via Web-Ex to support provider training on Carelon processes, contracting / credentialing and linkages for issue resolution, helping to improve provider experience and overall satisfaction with Carelon.
+ Acts as a liaison between strategic providers and Carelon clinical, quality, provider strategy, operations, and claims, to ensure interdepartmental collaboration and coordination of goals and priorities.
+ Supports regional and corporate initiatives regarding Carelon Select Provider (CSP) program, clinical innovation, and thought leadership transforming provider relationships from transactional interactions to collaboration.
+ Creates and maintains linkages between providers of all levels of care, as well as other community-based services and resources to improve transitions of care and continuity of services.
+ Partners with network providers and Carelon stakeholders to operationalize innovative programs and online resources to improve clinical and quality outcomes.
+ Analyzes provider reports pertaining to cost, utilization, and outcomes, and presents the data to providers and highlights trends.
+ Identifies data outliers and opportunities for improvement for individual providers.
+ Identifies high-performing and innovative providers who may be interested in new programmatic incentives or payment models.
+ Participates in the identification of opportunities for expansion and development of innovative pilot programs, implementation, launch, and efficacy and outcomes measurements.
+ Contributes to the identification of high-quality program ideas/designs into the local market to drive high levels of value.
+ Provides consultation to providers for clinically complex members as applicable.
+ Surfaces clinical and quality issues to regional clinical and quality teams and participates in helping to address concerns.
+ Conducts quarterly physician record reviews or as needed with network providers across all service levels.
+ Assists with provider orientations and provider training events in the region, when applicable.
+ Attends all accessible County BH provider meetings either in person or via telephone or Web-ex.
**Minimum requirements:**
+ Requires MA/MS or above in Behavioral Health field and a minimum of 10 years of progressively responsible professional experience in healthcare which includes a minimum of 5 years' experience in a behavioral health setting, either provider or payer; or any combination of education and experience, which would provide an equivalent background.
+ Current, valid, independent, and unrestricted license such as RN, LCSW, LMFT, LMHC, LPC, or Licensed Psychologist (as allowed by applicable by state laws) is required.
**Preferred Skills, Capabilities, and Experiences:**
+ Candidates who live in the Ventura or Los Angeles area HIGHLY preferred.
+ Behavioral Health experience preferred.
+ Travels to the worksite and other locations as necessary preferred.
+ Managed care experience preferred.
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $86,480 - $129,720.
Location: California
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Maintain provider data in the credentialing system, including adding new providers, updating existing providers and terminating providers when they leave the provider network. Set up contracted rates to assure provider contract compliance. Respond to requests from internal and external auditor regarding provider data accuracy and provider directory accuracy.

Required:

1. Associates degree or high school diploma/equivalent and/or two years experience working in health care operations, or equivalent experience with credentialing, claims, and provider data management.
2. Excellent communication and writing skills.
3. Experience in Microsoft Office (Excel, Word, Teams) and Adobe Acrobat with the ability to learn applications that support credentialing and provider data management processes.
4. General understanding of managed care plans and health insurance.
5. Critical thinking abilities along with the ability to work independently.
6. Proven time management and organizational skills.

Desired:

1. College degree preferred.
2. Experience with credentialing and provider data management system.

Responsibilities:

1. Maintain participating provider records in symplr Payer and the claims operating system with demographic, Tax ID, or other changes to ensure data accuracy.
2. Ensure newly contracted providers are accurately entered into symplr Payer.
3. Set up and maintain provider fee tables to ensure correct claims payment.
4. Enter credentialing applications to initiate the credentialing cycle.
5. Demonstrate compliance with NCQA NET 5, Element A-J and No Surprises Act to accurately populate provider directory information within the timely requirements.
6. Demonstrate compliance with NCQA NET 4, Elements A & B and state regulations to notify members of a provider termination within the timely requirements.
7. Manage returned mail, such as checks and EOPs, by researching and facilitating issue resolution,
8. Adhere to all The Health Plan (THP) policies and procedures, as well as, following regulations and standards established by NCQA, CMS, BMS, and the states where THP serves its members.
9. Research and resolve internal and external inquiries regarding provider status and system setup to ensure quality control.
10. Work collaboratively with the Provider Delivery Services team as well as all internal departments.
11. Assist with NCQA, CMS, BMS, state and internal audits.
12. Assist with training and development of employees related to provider data quality processes.
13. Maintain non-participating provider and dental records in the claims processing system with demographic, Tax ID, or other changes to ensure accuracy of information.
14. Create new non-participating provider and dental records in the claims processing system based on the information received on a claim.
15. Resolve data entry claims queue issues including data entry of non-participating providers.
16. Basic pay class assignment and maintenance to ensure the accuracy of claims payment.

Equal Opportunity Employer

The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

8:00am - 5:00pm
40

**Company :**
Highmark Inc.
**Job Description :**
**JOB SUMMARY**
***Required to report to office once monthly.**
This job manages a team of provider file representatives who are responsible for the system implementation of all provider contracts and provider demographics. Oversees an internal audit quality review program designed to ensure provider data accuracy and completeness, and to provide staff with feedback on their quality scores. Provides weekly management reports on quality, work-in-progress, volume trends and training opportunities. Responsible for training, updating departmental procedures, and ensuring consistent processes throughout the department.
**ESSENTIAL RESPONSIBILITIES**
+ Supervise non-exempt employees.
+ Oversee internal audit/quality review program.
+ Maintain and enforce departmental policies and procedures.
+ Train staff.
+ Meet internal and regulatory standards for timely data entry and report submissions and filings.
+ Inventory Management
+ Other duties as assigned or requested.
**QUALIFICATIONS**
**Minimum**
+ High school diploma or GED
+ 1 year of experience working with providers in areas such as enrollment and maintenance
+ 1-2 years of experience with staff oversight and/or development, either in a formal or informal capacity
**Preferred**
+ 1 year of experience performing Medicaid and /or Medicare systems setup of provider contracts and provider demographics
+ 3 years of experience in a provider data maintenance department of a managed care organization
+ Inventory management of production work load
+ Direct supervisory and/or management of staff (monitor day to day workloads, disciplinary reviews)
+ Project management
**Skills**
+ Demonstrated behavior showing the ability to manage the work of others in a volume-driven environment
+ Demonstrated work experience exhibiting strong business, analytical, judgment, and communication skills in a corporate environment
+ Knowledge of claims and various provider contracting methodologies
+ Understanding of software applications used Highmark Wholecare®, such as Managed Health Care System, CACTUS, OnBase Document Management and/or OnBase Workflow
+ Ability to communicate effectively in oral and written form to a wide range of audiences representing a broad cross-section of intellectual abilities and interests
**SCOPE OF RESPONSIBILITY**
Does this role supervise/manage other employees?
Yes, number of direct reports: 18
**WORK ENVIRONMENT**
Is Travel Required?
No
**_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._
**_Compliance Requirement:_** _This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies_
_As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy._
_Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._
**Pay Range Minimum:**
$50,200.00
**Pay Range Maximum:**
$91,200.00
_Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at
California Consumer Privacy Act Employees, Contractors, and Applicants Notice
Req ID: J268699

**Company :**
Highmark Inc.
**Job Description :**
**JOB SUMMARY**
***Required to report to office once monthly.**
This job manages a team of provider file representatives who are responsible for the system implementation of all provider contracts and provider demographics. Oversees an internal audit quality review program designed to ensure provider data accuracy and completeness, and to provide staff with feedback on their quality scores. Provides weekly management reports on quality, work-in-progress, volume trends and training opportunities. Responsible for training, updating departmental procedures, and ensuring consistent processes throughout the department.
**ESSENTIAL RESPONSIBILITIES**
+ Supervise non-exempt employees.
+ Oversee internal audit/quality review program.
+ Maintain and enforce departmental policies and procedures.
+ Train staff.
+ Meet internal and regulatory standards for timely data entry and report submissions and filings.
+ Inventory Management
+ Other duties as assigned or requested.
**QUALIFICATIONS**
**Minimum**
+ High school diploma or GED
+ 1 year of experience working with providers in areas such as enrollment and maintenance
+ 1-2 years of experience with staff oversight and/or development, either in a formal or informal capacity
**Preferred**
+ 1 year of experience performing Medicaid and /or Medicare systems setup of provider contracts and provider demographics
+ 3 years of experience in a provider data maintenance department of a managed care organization
+ Inventory management of production work load
+ Direct supervisory and/or management of staff (monitor day to day workloads, disciplinary reviews)
+ Project management
**Skills**
+ Demonstrated behavior showing the ability to manage the work of others in a volume-driven environment
+ Demonstrated work experience exhibiting strong business, analytical, judgment, and communication skills in a corporate environment
+ Knowledge of claims and various provider contracting methodologies
+ Understanding of software applications used Highmark Wholecare®, such as Managed Health Care System, CACTUS, OnBase Document Management and/or OnBase Workflow
+ Ability to communicate effectively in oral and written form to a wide range of audiences representing a broad cross-section of intellectual abilities and interests
**SCOPE OF RESPONSIBILITY**
Does this role supervise/manage other employees?
Yes, number of direct reports: 18
**WORK ENVIRONMENT**
Is Travel Required?
No
**_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._
**_Compliance Requirement:_** _This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies_
_As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy._
_Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._
**Pay Range Minimum:**
$50,200.00
**Pay Range Maximum:**
$91,200.00
_Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
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Req ID: J268699

**Job Description:**
The Provider Quality and Practice Transformation Manager is responsible for working directly with providers and care teams to build relationships and educate and implement structures and processes in alignment with population health management models.
The Manager will familiarize providers and their care teams with tools, reporting, and best practices and assist in the development of skills necessary to support meaningful changes in the way care is delivered. The incumbent assists providers/practices in utilizing analytic tools and practice level member data to improve coordination of care, quality metric performance, appropriate utilization, patient access, and patient outcomes. The incumbent collaborates with practice teams to create a culture of learning, coordinate activities, review work, exchange information, resolve problems, and proactively identify opportunities for improvement. The Manager provides on-site and remote support as providers and their practices work with SelectHealth Medical Home. This work requires frequent travel as the Manager visits practices to support with clinical practice improvement and transformation. Coordinates resources for other SelectHealth and Intermountain stakeholders who are impacted by medical home initiatives. Manages program requirement compliance / acts as project manager.
+ Consults and assesses practice/provider readiness for practice improvement and transformation and assists in clinical process transformation and improvement.
+ Supports clinic leadership in the oversight of clinical practice of assigned practices and provides clinical support within assigned sites.
+ Understands tools, reports, and best practices and utilizes understanding to inform practice improvement.
+ Provides infrastructure and education to empower providers and care teams to achieve desired clinical transformation outcomes.
+ Supports accountability for action items and follow-up on improvement plans.
+ Meets with practice staff based on action plans for improvement, facilitates ongoing discussions, drives progress, and addresses barriers.
+ Proficient in data and terminology necessary for population health management.
+ Lead continuous quality improvement discussions and exercises with clinic staff to elevate performance and efficiencies of workflows.
+ Expert in program reporting tools. Develop training and training materials to educate clinic staff and providers on actionable tools provided to program participants.
+ Maintain complete and accurate provider database to support contracting and performance reporting.
+ Responsible to monitor, analyze, and interpret operational performance of program participants. Work with clinics to develop action plans for deficiencies.
+ Shadow clinic staff to evaluate workflows and utilize continuous quality improvement expertise to help clinic staff identify root cause for issues and continuous quality improvement methods.
+ Manages the process of contracting new and existing providers to the program. Prepares contract documentation for providers who participate in Medical Home and pay-for-performance programs. Ensures accuracy of contract exhibits. Manages the maintenance of accurate records on the status and location of all contracted Medical Home practitioners.
+ Develops and maintains system databases for tracking and reporting of providers, provider compliance and assignments.
+ Oversees multiple databases and documentation repositories which provide access and information of providers and ensures information is accurate and updated. Audits and reviews accuracy of provider list databases. Coordinates with multiple departments and clinics to ensure updated provider and clinic information.
+ Works with high level professionals to develop agenda, procure necessary technical support, prepare materials, schedule and plan venue set up, and secures catering services as needed for annual best practice symposium events.
+ Provides support to Medical Home Consultants as needed. May perform chart audits related to provider pay-for-performance programs to ensure compliance to program requirements.
+ Works closely with the SelectHealth Provider Development team to coordinate provider communication, meetings, outreach, and escalations.
+ Responsible to escalate issues and barriers as well as program outcomes to SelectHealth Senior Leadership.
Job Detail
+ 20hrs/week
+ M-F (flexible based on clinic assignment and schedule)
+ Mainly remote position
+ Hybrid (Monthly in-person days, quarterly onsite clinic visits)
+ Quarterly travel to visit clinics onsite is a requirement
**Minimum Qualifications**
+ Bachelor's degree in a business-related field. Degree must be obtained through an accredited institution. Education is verified.
+ - **OR** - five years' experience in Project Management or Quality Improvement area.
+ Experience with basic computer programs, statistical analysis, and quality reviews.
+ Experience working in practice transformation.
+ Experience working in a high-pressure, dynamic, demanding, and ambiguous work environment.
+ Leadership experience including achieving results while working with others.
+ Experience with change management in large organizations.
+ Excellent presentation, interpersonal, and relationship-building skills.
+ High level of proficiency creating executive-facing deliverables.
**Preferred Qualifications**
+ Master's degree in a business-related field. Degree must be obtained through an accredited institution. Education is verified.
+ Health insurance experience or experience working in a clinical setting.
+ Experience in value-based care delivery and/or population health services.
+ Experience consulting within the healthcare setting
+ Experience working directly with physicians including using data to influence physician behavior.
+ Ability to analyze and interpret data and provide education to other customers.
**Physical Requirements:**
**Location:**
SelectHealth - Fort Collins, SelectHealth - Murray
**Work City:**
Murray
**Work State:**
Utah
**Scheduled Weekly Hours:**
20
The hourly range for this position is listed below. Actual hourly rate dependent upon experience.
$38.55 - $59.49
We care about your well-being - mind, body, and spirit - which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
Learn more about our comprehensive benefits package here ( .
Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
At Intermountain Health, we use the artificial intelligence ("AI") platform, HiredScore to improve your job application experience. HiredScore helps match your skills and experiences to the best jobs for you. While HiredScore assists in reviewing applications, all final decisions are made by Intermountain personnel to ensure fairness. We protect your privacy and follow strict data protection rules. Your information is safe and used only for recruitment. Thank you for considering a career with us and experiencing our AI-enhanced recruitment process.
All positions subject to close without notice.

Maven is the world's largest virtual clinic for women and families on a mission to make healthcare work for all of us. Maven's award-winning digital programs provide clinical, emotional, and financial support all in one platform, spanning fertility & family building, maternity & newborn care, parenting & pediatrics, and menopause & midlife. More than 2,000 employers and health plans trust Maven's end-to-end platform to improve clinical outcomes, reduce healthcare costs, and provide equity in benefits programs. Recognized for innovation and industry leadership, Maven has been named to the Time 100 Most Influential Companies, CNBC Disruptor 50, Fast Company Most Innovative Companies, and FORTUNE Best Places to Work. Founded in 2014 by CEO Kate Ryder, Maven has raised more than $425 million in funding from top healthcare and technology investors including General Catalyst, Sequoia, Dragoneer Investment Group, Oak HC/FT, StepStone Group, Icon Ventures, and Lux Capital. To learn more about Maven, visit us at mavenclinic.com.

An award-winning culture working towards an important mission - Maven Clinic is a recipient of over 30 workplace and innovation awards, including:

• Fortune Change the World (2024)
• CNBC Disruptor 50 List (2022, 2023, 2024)
• Fortune Best Workplaces for Millennials (2024)
• Fortune Best Workplaces in Health Care (2024)
• TIME 100 Most Influential Companies (2023)
• Fast Company Most Innovative Companies (2020, 2023)
• Built In Best Places to Work (2023)
• Fortune Best Workplaces NY (2020, 2021, 2022, 2023, 2024)
• Great Place to Work certified (2020, 2021, 2022, 2023, 2024)
• Fast Company Best Workplaces for Innovators (2022)
• Built In LGBTQIA+ Advocacy Award (2022)

Maven is looking for a Senior Provider Network Manager to lead the strategic execution and continuous evolution of our clinical quality programs, provider performance and engagement initiatives across Maven's provider network (W2 and 1099).

This role involves driving clinical quality programs, managing performance, ensuring provider engagement, and fostering strong relationships across the organization to optimize network effectiveness and deliver high-value care.

Key Responsibilities:

• Clinical Quality Program Management: (50%)
• Drive the design, implementation, and continuous improvement of clinical quality programs (e.g., clinical case reviews, prescription monitoring program, provider scorecard) that allow for assessment at individual and global levels.
• Partner with clinical leaders to standardize best practices and integrate clinical guidelines across network operations.
• Develop and maintain a centralized, user-friendly repository for all provider-facing clinical materials, ensuring a single source of truth and ease of access to critical clinical content.
• Strategically own, design, and continuously evolve a comprehensive provider engagement strategy that drive satisfaction and performance (e.g., recognition programs, communications, learning/development offerings)
• Provider Performance Management: (30%)
• Co-develop and operationalize provider performance management frameworks, including constructive feedback protocols, grievance resolution processes, and documentation standards.
• Partner with Sr. Medical Director and Practice Group Providers to address performance concerns, resolve member complaints, and ensure disciplinary actions are consistent with policy.
• Leverage dashboards and performance metrics to identify trends and provide actionable insights to senior leadership.
• Create consistent, effective communication channels for providers (e.g., newsletters, office hours, announcements) and ensure alignment with broader org communications to foster a cohesive and informed provider community.
• Strategic Leadership and Cross-Functional Collaboration: (20%)
• Lead proactive identification and resolution of complex, systemic challenges impacting provider care delivery, leveraging data and insights to drive impactful solutions.
• Build consensus and drive alignment across clinical leadership, product, engineering, and operations to ensure seamless integration of quality and engagement initiatives.
• Champion provider network voice across the organization ensuring initiatives are grounded in frontline feedback and business goals.
• Contribute to the development and execution of the broader provider network strategy, ensuring clinical quality and engagement are central pillars.
• Cultivate strong, collaborative relationships with key providers and stakeholders within the network.

Ideal Candidate Profile:

• Experience:
• 5-7 years of experience in clinical quality management, healthcare operations, or provider relations
• 5+ years of experience at a high-growth health tech company
• Experience project managing cross-functional initiatives in a matrixed organization (eg implementing new clinical protocols, integrating technology solutions, or rolling out new engagement initiatives).
• Demonstrated success in developing and scaling operational systems focused on clinical and service quality improvement.
• Applied experience with performance management, quality improvement methodologies, and provider relations.
• Skills:
• Strong organizational and program build-out capabilities, adept at structuring and scaling new initiatives
• Strong accountability for program results, proactively anticipates challenges, makes sound, data-driven trade-offs, and optimizes for both team efficiency and individual effectiveness.
• Exceptional verbal, written, and presentation skills, with the ability to communicate complex information clearly and concisely to diverse audiences.
• Analytical thinking and problem-solving skills with the ability to translate data into strategic recommendations and drive impactful change.
• Proficiency in data management and reporting; familiarity with data visualization tools (e.g., Looker, Tableau).
• Highly proactive and results-oriented with a strong sense of ownership.
• Ability to work effectively in a fast-paced, matrixed environment.
• Education:
• Bachelor's degree in a healthcare-related field or equivalent experience.

The base salary range for this role is $40,000- 175,000 per year. You will also be entitled to receive stock options and benefits. Individual pay decisions are based on a number of factors, including qualifications for the role, experience level, and skillset.

Maven embraces a flexible hybrid work model. Our teams primarily operate from the New York Metropolitan area, NY, San Francisco/Bay Area, CA, Seattle, WA, Boston, MA, Chicago, IL, and Washington, D.C. For those in our New York City office, we encourage in-person collaboration by requiring team members to work onsite three days a week (Tuesday, Wednesday, Thursday). For those based in San Francisco/Bay Area, CA, Seattle, WA, Boston, MA, Chicago, IL, and Washington, D.C., we encourage in-person collaboration by requiring team members to attend quarterly Work Together Days within these cities. This policy aims to balance remote work flexibility with the benefits of face-to-face interaction.

This role requires active work authorization in the US.

At Maven we believe that a diverse set of backgrounds and experiences enrich our teams and allow us to achieve above and beyond our goals. If you do not have experience in all of the areas detailed above, we hope that you will share your unique background with us in your application and how it can be additive to our teams.

At Maven we believe that a diverse set of backgrounds and experiences enrich our teams and allow us to achieve above and beyond our goals. If you do not have experience in all of the areas detailed above, we hope that you will share your unique background with us in your application and how it can be additive to our teams.

Benefits That Work For You

Our benefits are designed to support your health, well-being and career development, helping you thrive both personally and professionally. We remain focused on providing a competitive benefits package for our employees. On top of standards such as employer-covered health, dental, and insurance plan options, we offer an inclusive approach to benefits:

• Maven for Mavens: access to the full platform and specialists, including care for mental health, reproductive health, family planning and pediatrics.
• Whole-self care through wellness partnerships
• Hybrid work, in office meals, and work together days
• 16 weeks 100% paid parental leave and new parent stipend (for Mavens who've been with us for 1 year+)
• Annual professional development stipend and access to a personal career coach through Maven for Mavens
• 401K matching for US-based employees, with immediate vesting

These benefits are applicable to Maven Clinic Co., US-based, full-time employees only. 1099/Contract Providers are ineligible for these benefits.

Maven is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, or genetic information. Maven is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. Maven Clinic interview requests and job offers only originate from an @mavenclinic.com email address (e.g ). Maven Clinic will never ask for sensitive information to be delivered over email or phone. If you receive a scam issue or a security issue involving Maven Clinic please notify us at: For general and additional inquiries, please contact us at