Role Overview: The Director, Provider Network Performance & Engagement is responsible for leading strategies and initiatives to optimize provider network performance, advance value-based contracting, and strengthen provider relationships.
Work Arrangements:- Hybrid - Associate must reside in Michigan (MI) and work onsite at the Southfield, MI office two days per week.
Responsibilities:- Lead initiatives to monitor and improve provider performance, focusing on quality, efficiency, cost of care, and patient outcomes.
- Responsible for development and execution of annual provider network strategy to include network adequacy standards, value-based strategies to drive and improve outcomes and engagement, and strategies to deliver a market-competitive network.
- Analyze utilization and financial performance data to identify cost drivers and implement targeted interventions.
- Oversight of VBP negotiations, VBP Contract performance, and leading VBP strategies in collaboration with internal stakeholders.
- Monitor SCA and out-of-network utilization and trends, and develop contracting strategies to improve and increase in-network utilization.
- Responsible for departmental staffing decisions and provides supervision to assigned staff, writing and performing annual reviews, and monitors performance issues as they arise.
- Ensures department staff remain compliant in all aspects of Federal and State rules, regulations, policies, and procedures, and creates or modifies departmental policies to reflect changes.
- Establish key performance indicators (KPIs) and regularly report on network performance to executive leadership.
- Actively partners with the Market Director of Quality to drive Company-wide and Plan quality initiatives, such as Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and National Committee for Quality Assurance/Utilization Review Accreditation Commission (NCQA/URAC), and analytics teams to ensure alignment on performance strategies.
- Responsible for oversight of network adequacy monitoring and managing provider network, developing strategies to close gaps, and ensuring appropriate access to services throughout the Plan's territory.
- Oversight of large-scale provider terminations to include tracking, reporting, and identifying risks and strategies for gap closure and access.
- Ensures provider contracts are consistent with organizational guidelines, claim payment methodologies, and state and federal regulatory requirements.
- Ensures that non-standard contract elements are tracked and communicated to appropriate departments and obtains AHC and Plan approval before submission to the provider.
- Responsible for leading complex negotiations for facilities and value-based contracts for clinically integrated networks.
- Other duties as assigned.
Education & Experience:- Bachelor's degree required.
- 5 or more years of provider contracting experience with various reimbursement models.
- 10 or more years of healthcare strategy, provider relations, or network management.
- Managed care experience preferred
Skills & Abilities:- Strong knowledge of provider network management, provider contracting, and reimbursement methodologies.
- Demonstrated experience developing and executing provider network strategies that support quality, cost, access, and performance goals.
- Ability to lead value-based payment strategies, risk-sharing arrangements, and complex provider negotiations.
- Strong analytical skills with the ability to interpret utilization, financial, quality, and network performance data.
- Knowledge of network adequacy standards, access requirements, and state and federal managed care regulations.
- Ability to identify cost drivers, performance gaps, and provider access issues and develop targeted improvement strategies.
- Strong understanding of HEDIS, CAHPS, NCQA, and URAC quality standards.
- Excellent leadership and people management skills, including staff supervision, performance management, and departmental planning.
- Strong relationship-building skills with providers, executive leadership, internal departments, and external stakeholders.
- Excellent written and verbal communication skills, including the ability to present complex information to executive audiences.
- Ability to collaborate cross-functionally with quality, analytics, finance, operations, and compliance teams.
- Strong problem-solving, decision-making, and strategic planning skills in a fast-paced managed care environment.
