Jobs related to managing provider networks that support client base. This includes hospital, physician, dental, and pharmaceutical networks. Examples include provider relations activities, analyzing provider performance, creating provider reimbursement arrangements, and credentialing activities.
Positions in this function are responsible for the successful program design, compliance with network requirements, network assessment and selection, and program/product implementation. This includes enterprise-wide Clinically Integrated Network teams that focus on specific clinical area Lines of Service (e.g., Cardiology, Women's Health, Oncology, etc.) to improve the quality and affordability through improvements in appropriateness and effectiveness. May perform network analysis and strategy development and implementation. Obtains data, verifies validity of data, and analyzes data as required. Analyzes network availability and access.
May make recommendations regarding use, expansion, selection of networks for various products based on that analysis.
- Analyzes and investigates
- Provides explanations and interpretations within area of expertise
Job Scope and Guidelines- Uses pertinent data and facts to identify and solve a range of problems within area of expertise
- Investigates non-standard requests and problems, with some assistance from others
- Works exclusively within a specific knowledge area
- Prioritizes and organizes own work to meet deadlines
- Provides explanations and information to others on topics within area of expertise
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.
Primary Responsibilities:- NPM_Review/Analyze/Validate/Support Network and Provider Performance Data
- Review employer group/health plan expectations (e.g., commercial; government) in order to determine the potential impact to employer group/health plan membership
- Gather data from relevant sources in order to respond to stakeholders' requests (e.g., employer groups; internal teams)
- Analyze network and/or provider performance along key indicators (e.g., compliance with regulatory audits; financial performance; Benefit Cost Ratio; risk adjustment scores; prevalence rates; Unit Cost Reduction Trend) in order to determine which programs to implement and/or modify
- Research competitor and external information regarding key network characteristics and contracting strategies in order to develop products and programs
- Ensure relevant contract and demographic information is loaded into the applicable platform in order to support analysis and review
- Review and/or analyze member/provider population information (e.g., cultural information; demographics; geographic coverage) in order to determine potential network gaps in care and risk adjustment indicator opportunities
- Implement new rates with contracted providers based on provider performance
- Validate network data for programs (e.g., transparency program)
- Develop metrics and create performance reports for pay-for-performance programs (e.g., PBC; PCPI)
- NPM_Support/Develop/Drive Effective Network Programs
- Determine performance metrics and programs to apply to specific providers based on competitive data, internal data (e.g., provider improvement opportunities) and applicable legal and regulatory requirements
- Provide guidance to internal stakeholders regarding administration of contracts (e.g., contract language; coding) and advocacy. -Identify needs and create infrastructure and parameters for programs/networks/contracts (e.g., contract language; clinical quality initiatives; internal support)
- Communicate with key stakeholders (e.g., UHN Leadership, Advocates, network management contractors) to ensure programs/networks/contracts comply with standards
- Provide input and feedback to senior leadership in order to suggest/recommend improvements to programs/networks/contracts
- Coordinate with relevant internal and/or external stakeholders to ensure that programs/networks/contracts are designed and implemented to meet local, regional, and/or national market needs
- Work with Business Partners to create and/or implement communication/training materials (e.g., talking points; FAQs; step action chart; metric evaluation tools) in order to educate affected stakeholders on new programs and/or processes. Program Managers may contribute to documents.
- Network Program manager may conduct interactions with external health care providers to promote risk adjustment score accuracy
- (e.g., early detection; accurate documentation and coding) and compliance with applicable regulatory guidelines (e.g., CMS; HEDIS/STARS Quality Measures)
- Work with local, regional, and/or national networks and/or stakeholders in order build support for program/contract implementation
- NPM_Build/Manage Relationships with Network Program Management Stakeholders
- Seek feedback from relevant internal and/or external stakeholders regarding potential program/network improvement opportunities and needs
- Conduct proactive outreach with external stakeholders (e.g., health care providers; health plan) to demonstrate the value of services and offerings
- Collaborate with relevant internal and/or external stakeholders to resolve issues and obstacles with network/program/contract performance
- Collaborate with the contracting team to ensure adherence to internal contracting standards
- Communicate with applicable stakeholders to provide performance updates regarding program/contract implementation (e.g., objectives; goals; timelines; schedules; issues; performance against standard contract agreements)
- Follow up with stakeholders to ensure issues have been resolved and addressed effectively and timely
- Manage external relationships with third-party vendors to ensure program SLAs are met
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- Undergraduate degree or equivalent experience
- Demonstrate understanding of demographic systems (e.g., Emptoris; NDB)
- Demonstrate understanding of claims platforms (e.g., Galaxy; COSMOS; NICE; FACETS; Diamond; PPO-One, UNET)
- Demonstrate understanding of report generation and workflow management systems (e.g., ChartFinder; InSite; Sharepoint
Documentation; Salesforce) - Demonstrate understanding of contracting strategies (e.g., facility; ancillary; physician) in order to support field objectives/MBOs
- Demonstrate understanding of key provider/contract/network performance and/or risk adjustment indicators (e.g., prevalence rate; recapture rates; MWOV; RAF scores)
- Demonstrate understanding of provider group operations and stakeholder/client business models
- Demonstrate understanding of documentation and coding procedures (e.g., ICD-10)
- Demonstrate understanding of applicable health care regulations (e.g., HIPAA; ARRA; CMS, NCQA)
- Demonstrate understanding of operations of key business partners (e.g., Clinical Service; Medical Management; Health Care Economics, Provider Operations)
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
