Director, Provider Network and Operations
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Job Description
Director of Provider & Network Operations at Community Health Options. Overseeing provider relations, contracting, and network performance to meet company objectives.
Responsibilities:
- Responsible for assuring the financial viability, overall service, and quality and performance of provider networks.
- Oversees the development and implementation of provider contracting strategies and provider contracting negotiations and ensures the terms of the contracts are fulfilled.
- Leads provider contracting and servicing activities for business expansion.
- Develops and implements strategies to strengthen and/or develop new physician, hospital, and other provider relations.
- Defines provider network expansion requirements in new and existing geographic service areas, and for new lines of business.
- Approves and monitors special requests, retroactive adjustments, reimbursement, and contract exceptions.
- Modifies networks, their composition, contracts, reimbursements, credentialing standards and utilization trends as needed to assure goals are met.
- Collaborates with physicians and other organizations to develop and pursue mutually beneficial business opportunities to meet community needs for health care services.
- Maintains access to a high quality geographically desirable cost-effective network of specialists, hospitals, and ancillary providers to meet the needs of members served.
- Directs the implementation of new health plan contracts/product lines which respect to the Provider Network Management responsibilities.
- Directs rate analysis, scope assessment, and geographic coverage assessment prior to extending agreements to providers recruited to satisfy network needs.
- Oversees all primary IPA, Medical Group and Hospital market research to gain qualitative and quantitative data to bring definition to market strategies.
- Oversees initiatives to engage with local or regional Accountable Care Organizations (ACOs).
- Monitors industry changes, trends, and events to proactively identify opportunities to increase market penetration and performance improvement.
- Oversees recruitment of providers for new networks; optimizes size and composition of existing networks, and other projects necessary to meet business performance and growth goals.
- Ensures network providers meet quality, cost, and coverage standards, and comply with applicable laws, regulations, and accreditation requirements.
- Develops and manages team and corresponding budget as needed to assure success.
- Provides strategic direction to lead network development to enable continued growth, profitability, and industry leadership.
- Assists with provider relations activities as needed.
- Collaborates with internal teams including medical management, operations, and risk adjustment to align the network strategy with clinical and financial objectives.
- Update and interface with senior leadership team as appropriate on initiatives.
- Ensure network providers meet quality, cost, and coverage standards, and comply with applicable laws, regulations, and accreditation requirements.
- Oversees the determination and implementation of any health plan or regulatory corrective action plans related to provider network activities.
Requirements:
- Bachelor's degree is required and master's degree desirable
- Minimum 5 years of management experience
- A minimum of 5 years experience in provider contracting and provider relations
- Must understand Medicare, RBRVS, case rate, capitation, and other related payment structures.
Benefits:
- Health insurance
- Retirement plans
- Paid time off
- Flexible work arrangements
- Professional development
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