JOB SUMMARY: Responsible for oversight of all Provider services and network development functionality specific to the plan’s Medicaid product. Responsible for network adequacy activities, provider contracting, relationship development, provider education and communications and activities specific to operations as directed by the Senior Manager, Provider Network Administration.KEY RESPONSIBILITIES: Build and maintain network including recruitment of providers as needed to attain network expansion and adequacy targets. Develop network adequacy goals and conduct ongoing monitoring to ensure network adequacy compliance with standards established by the State.Participate in the design of value-based reimbursement models in support of business strategies. Participate in development of quality and utilization metrics to achieve healthy outcomes for Medicaid members. Guides, under the direction of the Senior Manager, Provider Network Administration, provider contracting with health systems, hospitals, physician groups, individual practitioners, ancillary services, and community based social services agencies. Facilitate the development of statewide network. Ensure, to the extent possible, consistency with all other product strategies. Ensure contracts meet all regulatory and accreditation requirements.Develop and maintain relationships with health systems and key provider groups leadership. Develop and maintain relationships with community and social service agencies onboarded to assist with Social Determinants of Health (SDOH). Guide provider services representatives to ensure resolution of escalated provider issues. Oversee the planning of plan sponsored health events.Develop and maintain provider manual. Develop and maintain provider education and communication materials. Collaborate with development of plan employee education materials. Assist plan provider relations staff with educating providers on Medicaid product, policies and procedures, and programs.Participate in product strategy development. Develop and recommend updates to policies and procedures. Review member complaints against providers to identify trends. Initiative and program planning. Resource to departments for problem solving provider related issues and contract interpretation. Review and analysis of applicable reports. Attends Medicaid specific operations / leadership meetings. Additional responsibilities as assigned by leadershipQUALIFICATIONS: Ability to process and understand complex information. Ability to organize and oversee multiple complex tasks/projects to completion. Ability to coordinate resources in an effective, cost-efficient manner. Excellent communication and interpersonal skills. Ability to interpret and communicate detailed technical and financial information. Demonstrated knowledge of physician and hospital capitation reimbursement methodologies. Familiarity with healthcare and managed care business operations environments. Strong familiarity with managed care terminology. Proficiency with software systems including Amisys, Microsoft Word and Excel. Ability to converse and write fluently in English. EDUCATION/EXPERIENCE: Bachelor’s degree plus 3 years work related experience. Managerial / Supervisory experience preferred. Demonstrate, through past performance and progressive increases in responsibility, the ability to accomplish goals. Excellent oral presentation and writing skills. Previous physician/hospital contracting and reimbursement development experience. Familiarity with providers and provider issues in a managed care environment. Previous claims software experience, preferably Amisys.CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national originOther details Pay Type Salary Apply Now
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Job ID: 2308931154
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