Senior Director, Network Management, Needed!

Senior Director, Network Management, Needed!

Full‑time

Under the general supervision of the Chief Operations Officer, the Senior Director, Network Management is responsible for leading all aspects of Provider Network Management at the organization. Responsibilities of this position include the development of the Plan’s provider network strategy, provider contracting, provider relations and operations to support provider service, network development, provider education, and product and market expansions.

The Senior Director will plan, direct, and organize strategic provider engagement activities with health systems, hospitals, and provider groups to ensure effective support for improving the health outcomes of health plan members, improving the quality of care and service they receive and reducing the total cost of care. The successful candidate provides direction and oversight to all provider network development and maintenance as well as coordination and deployment of reimbursement operations. This position works in concert with the other areas of the organization including health services, finance, compliance, government & regulatory relations and senior leadership. Additionally, this individual is a key contributor to the organization’s strategic processes and partnering with key business areas such as Marketing.

MAJOR FUNCTIONS AND ACCOUNTABILITIES:

Duties may include, but are not limited to, the following

• Establish the Plan’s Network Management strategic vision, objectives, and policies and procedures.
• Ensure that the Network Management Department has the appropriate skills and expertise to meet the ongoing business initiatives and create future leaders and staff bench strength within the team.
• Provide leadership to the Network Management team in line line with the organization’s core values by building a high performing team, holding, team members accountable for results within a culture of collaboration, trust and respect, that respect holds team members accountable for results.
• Negotiate, re‑negotiate and execute physician and/or provider contracts in accordance with company standards in order to maintain and enhance provider networks while meeting and exceeding accessibility, quality and financial goals.
• Design, develop and implement Value Based Programs that incent and reward quality and meet the goals of “triple aim.”
• Oversee analysis of claim trend data and/or market information to derive conclusions to support contract negotiations.
• Perform periodic analyses of the provider network from a cost, coverage, and growth perspective. Provide leadership in evaluating opportunities to expand or change the network to meet Plan goals.
• Evaluate the provider network and implement strategic plans to achieve organizational targets and financial objectives through effective primary care, specialty, hospital and ancillary provider contracting and contract management.
• Lead the health plan in network design and development strategies to support the growth and performance objectives of the health plan.
• Build and develop strong relationships with the provider community to ensure that contractual relationships lead to meaningful and effective partnerships that balance the best interests of the organization’s members, providers and the Ventura County healthcare community.
• Enhance the engagement and partnership between the plan and its providers through effective leadership of the Provider Advisory Committee (PAC).
• Support the tracking and evaluation of health system, hospital and provider group performance, including quality, experience, and total cost of care.
• Strategically align resources by continuously planning and organizing to meet initiatives.
• Establish quality control mechanisms for processes and continuously strive to improve operational efficiency through process redesign and data driven evaluation of performance.
• Collaborate on and coordinate activities with other departments in the Health Plan and other divisions to support the network and the members it serves.
• Ensure provider education (new provider orientation, provider education/seminars, ongoing visits, meetings, provider manuals/bulletins/newsletters, etc.) activities are done in a timely and cost‑effective manner to continuously improve relationships with network providers and the delivery of care to our membership.
• Ensure compliance with applicable regulatory and internal requirements, including network reports for the department and other internal or external clients, regulators, and accrediting bodies.
• Oversee the development and distribution of provider education information such as the Provider Manual, bulletins and newsletters. Oversee continuing education of contracted providers related to quality improvement and outreach initiatives, such as HEDIS disease management, health fairs, and other projects.
• Establish and ensure adherence to Medi‑Cal and the organization’s policies and procedures for all functional areas of responsibility.
• Develop, modify and implement an External Relations strategy and program on an annual basis and monitor key metrics at staff level to ensure a high quality of service delivery and resulting Provider Satisfaction as measured by formal Provider Satisfaction Surveys and resolution of escalated provider issues.
• Conduct an annual effectiveness review of all provider satisfaction initiatives.
• Work with the COO to develop future strategic plans for all areas of Network Management.

EXPERIENCE, TRAINING, AND QUALIFICATIONS:

Knowledge, Skills & Abilities

• Experience directing Network Management Contracting, Processes & Services is essential. Experience must include knowledge of managed care contracting and provider relations.
• Experience in managed care health plan policies and operations (Medi‑Cal managed care preferred)
• Experience in the development and implementation of value based provider reimbursement programs.
• Business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the health care industry serving a diverse social and ethnic population.
• Local, regional, state, and federal laws, ordinances, regulations, codes, precedents, government regulations, executive orders, and agency rules, as they relate to managed care, Medicaid and other related business and policies governing managed care issues and especially network requirements.
• Communicate effectively in writing, orally, and with others to assimilate, understand, and convey information, in a manner consistent with job functions.
• Represent the Plan effectively in contacts with providers, representatives of other agencies, and the public.
• Advanced computer skills that include MS Office products.

Education and Experience

A combination of experience and training that would provide the required knowledge, skills, and abilities would be qualifying. A typical way to obtain the knowledge, skills, and abilities would be:

• Bachelor’s degree from a regionally accredited college or university in an appropriate discipline, e.g., Business, Health Care or Public Administration is preferred. Advanced degree preferred.
• Previous experience dealing with Government programs both Medicaid and Medicare.
• A minimum of seven years of experience with Network Development and Management. Contracting and provider relations expertise is required. Knowledge of Managed Care particularly Medi‑Cal is desired.