Director of Provider Network Strategy & Management

Health New England   •  

Springfield, MA

Industry: Accounting, Finance & Insurance


8 - 10 years

Posted 32 days ago

Position Summary

The Director of Provider Network Strategy and Management is responsible for developing, implementing and managing the plan's network strategy for commercial and government program lines of business in accordance with financial, operational and quality objectives to include: network development and expansion, network design, network performance optimization, provider initiatives, and provider data operational efficiencies. This includes the development and enhancement of relationships with health systems, PHO’s and provider group executive leadership. The Director oversees all aspects of the provider contracting, operations and relationship management including: financial modeling and analysis in preparation of contract proposals and renewals, provider communication, education and relations, provider enrollment and credentialing and provider appeals. Serves as a key contributor in the development of company strategy, priorities and business planning. The Director is responsible for associate management and development.

Essential Functions:

Develop and Implement Network Strategy - 40%
- Responsible for network development and contracting strategy in conjunction with company priorities for all lines of business (Commercial, Medicare and Medicaid), including the evaluation of new business opportunities.
- Create and monitor annual provider contract budget.
- Direct and conduct financial modeling and analysis for provider contracts drafting and negotiation.
- Oversee the negotiations and monitoring of provider incentive programs to ensure the achievement of financial, quality, and clinical objectives through accomplishment of provider initiatives.
- Leads the investigation and implementation of new payment models such as Value Based Contracts, GIC payment reform initiatives, capitation models and bundled payments to support company goals/benchmarks for population health metrics on quality and cost of care and member satisfaction.
- Act as lead negotiator for PHO/ACO and hospital system contracts.
- Work with Director of Financial Services and Director of Quality and Population Health Analytics to create assessment methods and tools to measure provider performance against HNE targets to drive cost and quality improvement.
- Keep abreast and maintains familiarity with industry and government program (Medicare and Medicaid) trends, regulations, legislation, and payment rules and reimbursement methodologies.
- Participate in company strategy, policy and business planning.
- Member of the Medical Trend Committee: evaluate impacts of provider reimbursement changes on premium rate development.
- Provide support for development of new products and premium rates.
- Collaborate with Legal Dept. and outside counsel to resolve contract disputes.
- Promote HNE and its initiatives to outside parties.
- Direct Network Strategy and Provider Contract Review meetings.

Seamless provider operations – 40%
- Member of Directors' Team: participate in companywide goals and initiatives.
- Supervise Provider Relations, Provider Credentialing and enrollment, and Provider complaints and appeals and Provider Contracting teams.
- Ensure that relationships with providers are appropriately monitored and maintained to drive high provider satisfaction.
- Monitor and review provider satisfaction results and make recommends for improvements.
- Collaborate with internal departments to assess provider experience and identify areas of opportunity. Coordinate integration opportunities between internal departments connected with seamless provider operations.
- Ensure provider education (new provider orientation, on-going provider visits and meetings, Provider Manuals, Bulletins, Newsletters) activities are done in a timely and cost-effective manner to continuously improve relationships with network providers.
- Act as liaison between providers and provider senior leadership.
- Establish and report key metrics to track Department performance.
- Monitor for accurate implementation of payment provisions.
- Participates in Company-wide and Plan quality initiatives such as HEDIS, CAHPS and NCQA.

Staff management and development - 20%
- Manage, train, coach and develop associates.
- Develop staffing models and monitor capacity/capabilities of Teams.
- Lead Teams in a manner conducive to ongoing growth and expanded knowledge of associates.
- 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 in accordance with HNE’s high performance culture.
- Manage staff workflow and priorities.

Minimum Requirements

Bachelor’s degree or equivalent in Business or Health Care related field with a minimum 7 years of managed care contracting and negotiation experience and at least 5 years in management/leadership roles.

- Master's Degree in Business, Healthcare Administration or related field a plus
- Demonstrated negotiation and influencing experience.
- Strong knowledge of commercial and government provider reimbursement methodologies and risk sharing models.
- Expertise in Medicare and Medicaid payment rules and methodologies.
- Ability to use financial and utilization data to formulate rate proposals within budgeted financial targets and evaluate financial impact of changes in payment terms.
- Strong analytical skills
- Proficient in Microsoft Word, Excel and PowerPoint.
- Initiative and ability to solve problems at the strategic and tactical level.
- Demonstrates solid communication, interpersonal, relationship-building skills
- Ability to form and lead teams as necessary for development, and implementation of new or modified policies, programs or processes to support provider contracting objectives.
- Demonstrates team leadership, facilitation and coaching skills.