Bachelor's degree or 5+ years in senior management contracting/development
2-3 years of experience in the managed care industry
Strong knowledge of medical terminology, CPT coding, and billing procedures
Experience in data analysis and reporting in healthcare settings
Ability to lead teams and conduct training sessions
Responsibilities
Direct and support the Business Intelligence (BI) team to ensure compliance with service agreements and reporting requirements.
Oversee daily status meetings and contributions for staff and committee discussions.
Establish and analyze trends based on data projections and actual results.
Support the development of health care scopes of service for network contracts.
Lead analysis of provider performance profiles to identify outliers and variations.
Coordinate monthly meetings with network owners to address adequacy gaps in the provider network.
Prepare ad-hoc analyses and reports as requested by network entities.
Benefits
Collaborative work environment that supports innovation.
Opportunities for professional development and training.
Flexible scheduling to accommodate staff needs.
Participation in meaningful projects that impact healthcare delivery.
Ability to contribute to enhancing provider network quality and performance.
Full Job Description
Key Responsibilities
Direct, guide and support the activities of the Business Intelligence (BI) team in ensuring compliance with all client service level agreements, reporting requirements (e.g. Provider Network Vendor (PNV) reports), internal network reports (e.g. FFS/CAP comparison, monthly accessibility requirements), and any and all other data analysis as needed to support the Network Management team.
Oversee the daily status meetings with the Business Intelligence team.
Support the oversight of the contributions of the BI team for all staff and committee meetings.
Establish trends based on seasonality and data projections vs actuals.
Support the Organization with all relevant matters concerning contractual, financial and operational terms as stated in HN1's network agreements with Health Plans.
Support the development of health care scopes of services to Senior Management for contracts between HN1 and Providers and Health Plans.
Support the Sr. Director in the process to calculate and distribute the provider bonuses for all network entities: HN1, TN, EMI and EM.
Lead the BI team in the analysis of the provider profiles that are generated by IT each quarter, identifying providers who are outliers (e.g. under/over utilizers).
Lead the BI team in the creation of the reports of the provider profile specific for each network entity.
Train each network in the understanding of performance criteria, the letters and reports.
Review, define and change the criteria of the key indicator of each network entity as needed.
Support the Sr. Director in the preparation of quarterly and/or monthly network reports package for all network entities: HN1, TN, EMI and EM.
Prepare ad-hoc analyses upon request by the network entities.
Prepare the monthly and quarterly Quest reports to validate network adequacy in terms of provider ratios and time and distance for all network entities.
Coordinate monthly meetings with the network owners to review/cure Network Adequacy gaps.
Support the maintenance of all network demographics by creating a demographic exception report.
Train the staff on the use of the demographic exception report.
Support the network entities in the distribution of network newsletters/bulletins by providing a monthly report tool that contains all of the current distribution data (i.e. emails and fax numbers) at the provider contracting/TIN level, individual/NPI level, location and PWP.
Support the network entities in the tabulation of the provider satisfaction surveys results, production of the reports and power point summary if applicable
Support the network entities in the tabulation of the provider require training results, production of the reports and power point summary if applicable.
Develop and maintain familiarity with the managed care industry, such as the availability of outside sources of information, statutes affecting HN1 business, current industry trends, and general services/locations of major non-contracted health plans and providers.
Support the Sr. Director in all market research and maintenance of a master document of all 48 contiguous United States, territory of Puerto Rico and the USVI. This document shall contain all pertinent information related to the health care programs governed by both state and federal agencies, our competitors in this market, their market share, etc.
Support all new business in the acquiring, processing, analyses and creation of the financial proposals for each RFP/ITN.
Participate in meetings with prospective health plan clients as needed.
Support the Sr. Director in the management and support the CRM Zoho and DocuSign tools.
Support the Sr. Director in the creation and maintenance of a contract "snap shot" of each contracted client.
Support the Sr. Director in the creation and maintenance of different dashboards and reports solution with the use of Power BI tool.
Support the executive leadership team as needed.
Knowledge of medical terminology, CPT coding, and billing procedures.
Strong contracting background.
Must support company philosophies, objectives, decisions, and policies.
Ensure adherence to department and organizational standards, policies and procedures, including HIPAA.
Ensure integrity of data entered into Company systems and/or databases.
Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
Ability to work the regular schedule and shift for the position.
Additional travel for meetings with health plan clients as needed.
Compliance with all personnel policies and procedures.
Perform additional duties and related essential duties as assigned
Required Education and Experience:
Bachelor's degree (B.A.) or five (5) plus years senior management contracting/development experience.
Two or three years extensive working background in the managed care industry.
Supervisory Responsibilities:
Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws.
