Director Provider Network Management

Responsibilities:

Responsible for all hospital, physician and physician extender network development and management. This position is also responsible for implementing strategies to improve provider satisfaction. This position will interact with Hospital and Physician Practice Chief Executive Officers, Chief Financial Officers, Directors of Managed Care and other high level executives. Ensures department achieves annual goals and objectives.

• Responsible for strategic planning of hospital and physician network development and management.
• Ensures compliance with pricing guidelines established by AHC and Plan.
• Complies with established contract implementation process(s) for all contracts.
• Ensures department staff remains current in all aspects of Federal and State rules, regulations, policies and procedures and creates or modifies departmental policies to reflect changes.
• Ensures provider contracting is consistent with claim payment methodologies.
• Responsible for implementation of electronic strategies for provider network to include increasing electronic claims submission and implementation of improved processes that result in increased auto-adjudication of claims.
• Maintains familiarity with State Medicaid fee schedules and analyzes comparable Plan pricing guidelines.
• Ensures provider contracting policies are adhered to as related to standard contract language.
• Ensures that non-standard contract elements are communicated to appropriate departments and obtains AHC and Plan approval prior to submission to provider.
• Responsible for compliance with network adequacy standards.
• Ensures the provider network meets the health care needs of Plan members.
• Establishes a recruitment plan, conducts recruiting activities and oversees the recruitment efforts of staff.
• Augments and modifies the existing provider network to accommodate new products or clients as necessary.
• Ensures provider communication and education meets AHC and Plan needs and functions as the liaison with the designated provider community.
• Leads team in a manner conducive to ongoing growth and expanded knowledge of associates.
  
  • Coach team members in the use of data and appropriate analytical tools that support improved quality.
  • Support team members in the identification and creative problem resolution for improved processes and expanded use of technology.
  • Systematically keeps staff informed of policy and procedural changes affecting program and administrative operations.
• Resolves individual provider complaints in a timely manner to ensure minimal disruption of the Plans network.
• Ensures capitation, provider rosters, and RHC/FQHC reports are monitored and strategies are developed and plans are implemented to address outliers.
• Drives Company-wide and Plan quality initiatives such as HEDIS, CAHPS and NCQA/URAC.
• Ensures the achievement of financial, quality, and clinical objectives through accomplishment of provider initiatives.
• Responsible for departmental staffing decisions and provides supervision to assigned staff, writes and performs annual reviews and monitors performance issues as they arise.
• Regularly suggests innovative means of structuring operations in a fashion that helps alleviate backlogs and ensures the optimal utilization of resources.
• Coordinates departments efforts with those of other departments.
• Reviews reports on annual provider satisfaction surveys; ensures the development of plans to improve identified areas of concern; works with other departments to develop quality assurance initiatives based on survey results.
• Develops and ensures compliance of department budget.
• Participates in Plan and physician committees as appropriate.
• Performs other related duties and projects as assigned.
• Adheres to AHC policies and procedures.

Education/Experience:

• Bachelors degree in Business or health related disciplines such as Healthcare Administration or Healthcare management or equivalent business experience. Masters Degree preferred.
• A minimum of 3 years Managed Care Provider Contracting and Reimbursement experience to include in depth knowledge of reimbursement methodologies and contracting terms.
• 1-2 years Medicaid experience preferred.
• Minimum 810 years of progressive business management and negotiation experience.
• Minimum 5 years management experience, managing teams and project management.
• A valid Drivers License and current Auto Insurance required.