VP Network Management

Job Summary The Vice President, Network Management is responsible for the strategic direction and oversight for all non-clinical provider-facing functions including provider contracting, provider relations, credentialing, and network administration. Directs the strategic development and maintenance of Community's network of providers for all programs and lines of business. Leads the development, implementation and maintenance of a robust provider engagement program that rewards and incentivizes providers to achieve Community's goals, including the movement of provider contracts to a value-based payment methodology. Responsible for the provider education program for all of Community's provider networks. Ensures accurate, timely and compliant communication with providers regarding claims payments. Reports to Position Title: EVP, Chief Operating Office. Job Responsibilities Leads the development of network strategies and innovative reimbursement and risk models to align provider incentives around performance. Ensures the network composition includes an appropriate distribution of provider specialties to achieve network adequacy requirements. Negotiates and/or oversees the negotiation of hospital, physician and ancillary provider contracts that allow achievement of company financial performance targets through existing and innovative compensation methodologies. Works with the Finance analytics team, Medical Management workgroup, and Executive Team as needed to make essential data-driven decisions. Monitors the financial performance of the contractual arrangements. Ensures all operations, communications, contract documents and daily interactions with providers remain compliant with regulatory and accreditation standards. Ensures an accurate, timely, and frequently maintained provider directory. Ensures timely and accurate submission of regulatory and compliance reports associated with the network contracting and management. Monitors compliance with contracting standards, reimbursement methodologies and the application of model contract language. Works closely with Configuration and Provider Data to oversee contract set-up and configuration to ensure accurate claims adjudication. Establishes and updates as needed CHC's provider contracting and relations policies and procedures, CGHC provider contractual materials and CGHC's provider manual. Ensures providers are effectively informed and updated as necessary. Monitors and reports significant developments occurring within the provider community and assists in developing a strategic plan to mitigate risks and capitalize on opportunities. Assists CHC and CHC-contracted vendors with necessary provider outreach related to claims submission efforts and medical record retrieval to support EDGE reporting and risk adjustment activities. Directly supervises leadership positions in the following functions, and indirectly all departmental staff: Contracting Provider Relations Value Based Contracting Network Administration Develops annual departmental budgets and monitors expenditures to meet administrative cost targets. Actively contributes to achievement of departmental goals, as identified in the department's annual business plan, including specific departmental process improvement plans. Minimum Qualifications Education/Specialized Training/Licensure: Bachelor's degree in healthcare, business, marketing or related field; MBA, Master of Public Health or Health Administration strongly preferred. Work Experience (Years and Area): Ten years in a patient care or managed care organization. Experience in contract negotiation, provider relations, network administration and claims processing/audit required. Management Experience: Five years of management experience. Software Operated: Microsoft Office (Word, Excel, Outlook). Other Requirements Experience in developing and implementing strategies and objectives for assigned areas of oversight, assuring alignment with organizational strategies and objectives. Ability to develop and manage departmental budgets, achieve financial targets. Demonstrated ability to proactively identify and analyze the root cause of challenges and concerns, breaking down a systemic issue into component parts and addressing bottlenecks and/or breakdowns. Experience with claims processing software and CRM systems required; experience with QNXT, Salesforce, PeopleSoft and PowerBI preferred. Contract negotiation skills required. Excellent communication skills, including communication with providers and regulatory oversight agencies. Demonstrated flexibility and ability to quickly adapt to new situations and challenges. Skilled at delegation, management and development of staff. Ability to inspire confidence and create trust. Additional Information Work Schedule: Hybrid. EMPLOYEE SUPERVISED: Professional and Clerical Staff. #J-18808-Ljbffr Community Health Choice, Inc.