Director Provider Network and Operations

POSITION SUMMARY

The Director, Provider & Network Operations is responsible for providing guidance and oversight over network management including Provider Relations, Provider Contracting, Credentialing, and Provider Data Integrity. The Director will exhibit insight, innovation, and leadership to drive multiple strategies while continuously improving quality, financial viability, access, and provider satisfaction. The position will assist in developing, leading, aligning and implementing the execution of tactical initiatives and strategies. In partnership with the Senior Vice President, CFO and Senior Leadership, the Director will integrate provider network plans, activities, and policies throughout the department in order to meet company objectives. The position is responsible for monitoring all aspects of the network, provider performance and trends to ensure networks are developed and suitable to meet business needs. The Director will serve as a liaison between the organization, hospital leaders and physicians to develop, communicate and execute strategic direction for the network. This position will also be directly involved in contracting discussions with larger and more complex partner arrangements.

ESSENTIAL FUNCTIONS AND 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.

JOB SPECIFIC KEY COMPETENCIES (KSAs)

• Working knowledge of eligibility, claims, credentialing, and utilization management preferred.
• The ability to develop and maintain excellent professional relationships within and outside the organization
• Strong verbal and written communication skills; must be able to effectively communicate to all levels of constituents, including prospects, members, providers, brokers, team members and senior management.
• Superior customer service support is essential
• Excellent organizational and time management skills

DIVERSITY, EQUITY, AND INCLUSION STATEMENT

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:

• Respectful, open communication and cooperation between all employees.
• Teamwork and participation, encouraging the representation of all groups and employee perspectives.
• Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

QUALIFICATIONS AND CORE 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.

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