Director, Provider Network and Operations

This is a fully remote position, open to applicants in Maine.

📋 Description

• Accountable for ensuring the financial sustainability, overall service quality, and performance of provider networks.

• Manages the creation and execution of provider contracting strategies, as well as negotiations, ensuring all contract terms are honored.

• Leads provider contracting and service initiatives aimed at business growth.

• Develops and executes strategies to enhance and/or establish new relationships with physicians, hospitals, and other providers.

• Identifies requirements for expanding provider networks in both new and existing geographic service areas, as well as for new business lines.

• Approves and oversees special requests, retroactive adjustments, reimbursements, and exceptions to contracts.

• Adjusts networks, their structure, contracts, reimbursements, credentialing standards, and utilization trends as necessary to ensure objectives are achieved.

• Collaborates with physicians and other entities to create and pursue mutually advantageous business opportunities that address community healthcare needs.

• Maintains access to a high-quality, geographically accessible, and cost-effective network of specialists, hospitals, and ancillary providers to cater to member needs.

• Directs the rollout of new health plan contracts and product lines concerning Provider Network Management responsibilities.

• Oversees rate analysis, scope evaluation, and geographic coverage analysis before extending agreements to providers recruited to fulfill network requirements.

• Manages all primary IPA, Medical Group, and Hospital market research to gather qualitative and quantitative insights that inform market strategies.

• Supervises initiatives to engage with local or regional Accountable Care Organizations (ACOs).

• Monitors industry developments, trends, and events to proactively uncover opportunities for market expansion and performance enhancement.

• Oversees the recruitment of providers for new networks; optimizes the size and composition of existing networks and manages other projects necessary for achieving business performance and growth targets.

• Ensures network providers comply with quality, cost, and coverage standards, as well as relevant laws, regulations, and accreditation requirements.

• Develops and manages a team along with the corresponding budget to ensure success.

• Provides strategic leadership to guide network development for ongoing growth, profitability, and industry leadership.

• Assists with provider relations activities as necessary.

• Collaborates with internal teams, including medical management, operations, and risk adjustment, to align network strategies with clinical and financial goals.

• Updates and communicates with the senior leadership team as appropriate regarding initiatives.

• Ensures compliance of network providers with quality, cost, and coverage standards, as well as applicable laws, regulations, and accreditation requirements.

• Oversees the determination and implementation of any corrective action plans related to provider network activities, whether health plan or regulatory in nature.

⛳️ Requirements

• A bachelor's degree is mandatory, while a master's degree is preferred.

• At least 5 years of management experience is required.

• A minimum of 5 years of experience in provider contracting and provider relations is essential.

• Must possess a thorough understanding of Medicare, RBRVS, case rates, capitation, and other related payment models.

🏝️ Benefits

• Health insurance

• Retirement plans

• Paid time off

• Flexible work arrangements

• Professional development