Responsible for operating and overseeing the day-to-day operations of the Specialty Provider Networks for which the respective individual manages for Health Network One (HN1).
Essential Functions & Responsibilities
Recruit, negotiate and contract physician providers in the specialty(ies) for which one is assigned.
Act as a liaison between HN1 and contracted health plans concerning all aspects of network participation.
Maintain strong working relationships with all contracted specialty/primary care/ancillary providers, acting as their key support in all aspects of their contractual relationship with HN1.
Analyze the utilization and cost performance of the specialty/primary care/ancillary network, maintaining a MLR of 85% or below for specialty/primary care/ancillary networks for which one is assigned.
Direct, guide and support the activities of any Network Development staff that supports these Provider Networks (PN).
Advise senior management of both the strengths and weaknesses in the PN and institute or recommend changes which better serve the organization and its assigned membership.
Develop and maintain a close working relationship with the TPA operations staff and work interdependently with each Department: Claims, Utilization Management, Credentialing and Provider File Maintenance.
Develop and maintain familiarity with the managed care industry, such as availability of
outside sources of information, statutes affecting HN1 business, current industry trends, and general services/locations of major non-contracted providers.
Attend all staff and committee meetings as requested by the Vice President of Network Operations and/or President & COO, including evening quarterly Executive Committee Meeting.
Must be able to travel to contracted physicians’ offices as needed.
Must support company philosophies, objectives, decisions and policies.
Ensure adherence to department and organizational standards, policies and procedures, including HIPAA.
Ensure integrity of data entered into Company systems and/or databases.
Must be familiar with various aspects of billing, claims adjudication and claims payment for the specialties assigned. This should include, but may not be limited to CPT Coding, ICD Code Sets, and CMS Fee Schedules.
Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
Ability to come to work and work the regular schedule and shift for the position.
Compliance with all personnel policies and procedures.
Perform additional duties and related essential duties as assigned.
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Education and/or Experience
Bachelor's degree (B. A.) and/or five (5) plus years senior management contracting/development experience.
Two or three years of extensive background in the managed care industry.
Certificates, Licenses, Registrations
Valid State Drivers License, required.
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