Director, Provider Network and Operations

🕒 May 2

🦞 Maine – Remote

🦞 Maine – Remote

⏰ Full Time

🔴 Lead

⚙️ Operations

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Community Health Options

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2012

⚕️ Healthcare Insurance

Healthcare Insurance • Insurance

Community Health Options is a Maine-based health insurance provider dedicated to offering flexible and affordable health plans for individuals and families, as well as small and large groups. They focus on providing comprehensive healthcare coverage with a wide network of in-network providers, while also offering wellness programs, virtual care options, and specialized support for chronic illnesses. Their mission centers around delivering benefits designed to meet the real needs of their members, while helping to reduce out-of-pocket healthcare costs.

📋 Description

• 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.

🎯 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.

🏖️ Benefits

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