Director, Provider Network and Operations

🕒 Maio 2

🦞 Maine – Remoto

🦞 Maine – Remote

⏰ Tempo Integral

🔴 Especialista

⚙️ Operações

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Community Health Options

SiteLinkedInTodas as Vagas

51 - 200 funcionários

Fundada em 2012

⚕️ Seguro de Saúde

Healthcare Insurance • Insurance

A Community Health Options é uma provedora de seguro de saúde com sede no Maine, dedicada a oferecer planos de saúde flexíveis e acessíveis para indivíduos e famílias, bem como para grupos pequenos e grandes. Eles se concentram em fornecer cobertura abrangente de saúde com uma ampla rede de prestadores credenciados, além de oferecer programas de bem-estar, opções de atendimento virtual e suporte especializado para doenças crônicas. Sua missão é entregar benefícios projetados para atender às reais necessidades de seus membros, enquanto ajudam a reduzir os custos de saúde fora do bolso.

Descrição

• 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.

🎯 Requisitos

• 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.

🏖️ Benefícios

• Health insurance • Retirement plans • Paid time off • Flexible work arrangements • Professional development