Position Overview:The Senior Director of Provider Network Operations is accountable for the performance and experience of the MetroPlusHealth network. This includes performance monitoring, operations, management and accuracy of provider directory, data, regulatory compliance, communications and training. Success in this role will be measured by high-performing and successful provider partnerships, ensuring excellent provider experience, accuracy of our provider directory and optimal results with access and availability leading to positive member experiences.
Scope of Role & Responsibilities: - Oversee the company Provider Data Management strategy
- Improve the overall provider experience by soliciting feedback in the annual provider survey and acting on areas for improvement.
- Ensuring quick and complete resolution of issues relating to reimbursement, directory information, and the overall patient experience.
- Seek continuous improvement of operational efficiency, recommending automated solutions, and operational analyses to identify areas of improvement.
- Using network performance data, identify and execute on strategies to improve company performance on financials, quality, risk adjustment, member retention and growth activities.
- Contribute as a key member of the Senior Leadership Team and other committees addressing the strategic goals of the department and organization.
- Monitor and assess network adequacy to meet federal and state regulatory guidelines.
- Ensure regulatory compliance of provider access and availability standards, including oversight of vendor activities.
- Oversight of provider data accuracy, including vendor activities and the resolution of discrepancies resulting in a more accurate directory and reduced claims issues.
- Review network reimbursement issues, trends, and root cause analysis and executing on strategies to reduce claims payment discrepancies.
- Collaborate with internal functions on business analyses, strategic planning, implementation of new business acquisitions and changing corporate requirements.
- Manage and lead the team, assisting with their individual success, fostering a culture of accountability, collaboration, and continuous improvement.
Required Education, Training & Professional Experience: - Bachelor's Degree in Business Administration, Healthcare, or any analytical field required; Master's Degree preferred.
- Minimum of 7 years of combined network management, credentialing, or regulatory affairs experience, operations, claims preferably in a managed care or insurance environment.
- Data management, data analytics, quality assurance, and project management skills required.
- Working knowledge of Medicare and Medicaid required.
- Ability to efficiently standardize and reconcile disparate data effectively.
Licensure and/or Certification Required: Professional Competencies: - Integrity and Trust
- Customer Focus
- Functional/Technical Skills
- Strong leadership attributes and the ability to manage both individuals and multiple high priority initiatives
- Effective oral, written, and interpersonal communication skills required.
