Director, Provider Network Management

The Director, Provider Network Management is a highly collaborative leadership role responsible for interfacing with the provider community and supporting ongoing provider relationships. This role requires critical thinking and problem-solving skills, strong communication skills, and high attention to detail. This role leads provider contracting professionals responsible for provider network development and negotiating new and existing contracts. The Director, Provider Network Management is responsible for implementing financially sound contracting strategies in a defined market and/or region. The director leverages and analyzes data to identify opportunities to improve provider performance including but not limited to re-negotiation of existing contracts, Value Based Agreements and Alternative Payment Model Programs, and partners with the Clinical, Operations and Finance teams to operationalize, administer, and monitor those contracts and programs. The director is also accountable for team development, team performance and monitoring team performance against key performance indicators (KPIs). The director assures policies and procedures are developed and tracked to demonstrate compliance with State and Federal regulations.

Requirements:

• Four (4) year college degree in healthcare administration, business administration, marketing, or related field.
• Three (3) years of progressively more responsible experience in provider-related areas in a managed care plan, consultant role or a hospital health system/integrated delivery system.
• Five (5) years direct supervisory experience.
• Knowledge of contracting language, the principles of negotiation and the ability to understand different types of reimbursement models.
• Ability to negotiate effectively.
• Knowledge of provider relationship management and outreach to improve quality of care delivered to members.
• Strong understanding of HEDIS, CMS Star Ratings and NCQA standards.
• Must be able to apply corporate policies and procedures to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
• Interpret a variety of instructions in written, oral or diagrammatic form.
• Superior written and oral communication skills.
• Valid drivers’ license.

Desired:

• Graduate degree preferred.
• Knowledge of healthcare finance principals.
• Knowledge of healthcare quality initiatives.
• Knowledge of performance-based contracting.
• Existing West Virginia, and/or Ohio, and/or Pennsylvania healthcare relationships.

Responsibilities:

• Establish and maintain the provider network in geographically accessible locations to serve the needs of the populations served.
• Ensure sufficient provider contracts for physical and behavioral health services to maintain access to care in accordance with Federal and State network adequacy standards.
• Develop and submit written network adequacy documentation.
• Lead hospital and health system physical health and behavioral health negotiations and renegotiations with a comprehensive, all-products approach including creative payment arrangements and Alternative Payment models to achieve corporate goals.
• Oversee physical health and behavioral health provider contracting documents and addenda.
• Support physical health and behavioral health provider credentialing activities.
• Support provider education and communication strategies to increase provider satisfaction across multiple markets and product lines.
• Develop provider and staff training to support the special needs of the populations served.
• Establish and maintain trusted relationships with physician, hospital and ancillary network participants.
• Coordinate provider contracting aligned with corporate strategies.
• Evaluate and monitor providers’ performance standards and financial performance of contracts.
• Serve as content expert in Value Based Agreements, Alternative Payment Model programs, Risk Adjustment programs, performance improvement and resolution of operational barriers impacting provider performance.
• Represent The Health Plan at external Joint Operating Committees with providers and at key strategic provider meetings.
• Analyze and interpret financial trends for health care costs, administrative expenses and provider quality/bonus performance.
• Leverage data to identify opportunities to improve provider performance under Value Based Agreements and Alternative Payment Model Programs.
• Partner with the Clinical, Operations and Finance teams to operationalize, administer and monitor those contracts and programs.
• Deliver National Committee for Quality Assurance (NCQA) network standards.
• Create key performance indicators (KPIs) to develop a high-performing team.