Responsible for managing the day-to-day activities of the Network Management department and staff. Responsible for assisting the Leader with departmental activities related to provider satisfaction, education, and communication. This position is also responsible for all provider network recruiting and contracting management activities. Ensures that the department and staff remain current in all aspects of Federal and State rules, regulations, policies and procedures and creates or modifies departmental policies to reflect changes. Ensures department achieves annual goals and objectives.
- Responsible for hospital and physician network development and management.
- Develops and recommends policy changes related to provider recruitment and contracting.
- Recruits and negotiates contracts with specific providers within operational and potential new counties to meet company requirements.
- Oversees training and communication for network providers and acts as a liaison with the provider community.
- Ensures compliance with pricing guidelines established by AMC and Plan.
- Ensures provider contracting is consistent with claim payment methodologies.
- Maintains familiarity with State Medicaid fee schedules and analyzes comparable Plan pricing guidelines.
- Resolves difficult complex contract issues to ensure that provider contracts are in compliance with state, federal, national accrediting agencies and Plan contracting guidelines.
- Ensures that non-standard contract elements are communicated to appropriate departments and obtains AMFC and Plan approval prior to submission to provider.
- Responsible for the accuracy and timely management of all provider contracts.
- 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.
- Responsible for compliance with State and accrediting agencies’ 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.
- Establishes a priority list of new geographic locations and types of providers to be added to the Plan network in concert with Plan departments.
- Works with Plan departments to retain network providers at risk for termination.
- Augments and modifies the existing provider network to accommodate new products or clients as necessary.
General Administrative Activities
- Responsible for departmental staffing decisions and provides supervision to assigned staff, writes and performs annual reviews and monitors performance issues as they arise.
- 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.
- Support collaborative team efforts that produce effective working relationships and trust.
- Systematically keeps staff informed of policy and procedural changes affecting program and administrative operations.
- Regularly suggests innovative means of structuring operations in a fashion that helps alleviate backlogs and ensures the optimal utilization of resources.
- Resolves individual provider complaints in a timely manner to ensure minimal disruption of the Plan’s network.
- Analyzes and monitors provider claim compliance with Plan policies and procedures and recommends solutions when problems occur.
- Responsible for facilitating the department on system upgrades, regulatory directives (i.e., Medicaid Bulletins, etc.) and assigned corporate initiatives.
- Monitors capitation, provider rosters, and RHC/FQHC reports and develops and implements strategies to address outliers.
- Conducts and prepares reports on annual provider satisfaction surveys; develops plans to improve identified areas of concern; works with other departments to develop quality assurance initiatives based on survey results.
- Supports the Quality Management Department and Company-wide Quality Initiatives such as HEDIS, CAHPS and NCQA/URAC:
- Reviews Quality indicators and makes recommendations for improvement
- Compiles documentation regarding quality Reports and provider utilization platforms.
- Will partner with medical management team to identify and measure methods to improve process and workflows
- Participates in Plan and physician committees as appropriate.
- Bachelor’s degree in business or health related discipline such as Healthcare Administration or Healthcare Management or equivalent business experience required.
- Master’s Degree preferred.
- 1- 3 years Medicaid experience preferred.
- 5 years provider contracting/reimbursement experience in healthcare setting.
- 3 years of effective and successful upervisory/management/leadership experience, preferably in a managed care setting.
- Valid driver’s license and current auto insurance required.
16 hours ago