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 strategies for provider contracting and negotiations, ensuring compliance with contract terms.

• Leads activities related to provider contracting and servicing to facilitate business growth.

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

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

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

• Adjusts networks, including their composition, contracts, reimbursements, credentialing standards, and utilization trends as necessary to achieve objectives.

• Works collaboratively with physicians and other organizations to identify and pursue mutually advantageous business opportunities to fulfill community health care needs.

• Ensures access to a high-quality, geographically desirable, and cost-effective network of specialists, hospitals, and ancillary providers to cater to the needs of members served.

• Directs the implementation of new health plan contracts/product lines in relation to Provider Network Management responsibilities.

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

• Manages all primary IPA, Medical Group, and Hospital market research to obtain qualitative and quantitative data for defining market strategies.

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

• Tracks industry changes, trends, and events to proactively identify opportunities for enhancing market penetration and performance improvement.

• Oversees the recruitment of providers for new networks; optimizes the size and composition of existing networks, along with other projects required to achieve business performance and growth objectives.

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

• Develops and manages the team and corresponding budget as necessary to ensure success.

• Provides strategic guidance to lead network development for sustained growth, profitability, and industry leadership.

• Assists with provider relations activities when needed.

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

• Updates and interfaces with the senior leadership team as appropriate on various initiatives.

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

• Oversees the determination and execution of any health plan or regulatory corrective action plans related to provider network activities.

⛳️ Requirements

• A bachelor's degree is mandatory; 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 solid understanding of Medicare, RBRVS, case rates, capitation, and other related payment structures.

🏝️ Benefits

• Health insurance

• Retirement plans

• Paid time off

• Flexible work arrangements

• Professional development