Assoc. Director of Network and Medical Costs
The Associate Director, Network and Medical Costs is responsible for network growth and development. The role is responsible to monitor operational performance, contractual compliance, supporting provider development, contracting and supporting provider relationship management.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Partners with Senior Management and other departments to build a comprehensive network strategy to support market growth in Health Plans and Insurance Services.
- Builds, refines and performance manage tiered network of preferred external specialists and facilities to form Provider Network.
- Performs in-depth analyses on the market place to identify current and future needs in Healthcare and current performance of provider network. Identify ways that Health Plans provider network can be diversified to accommodate current and future client needs, improve quality and reduce costs of service.
- Maintains knowledge of medical trends, cost drivers and cost saving opportunities.
- Leads referrals team and process (review, process, authorization, follow-up and coordination with providers.).
- Creation of and implementation of new service lines such as collaborative psychiatric care and emergency paramedic home visiting.
- Works with various departments (operations, legal, and client management) to ensure contracts meet operating, financial and legal standards.
- Ensures compliance with government programs such as Medicaid and Medicare for all contracting and network development purposes.
- Implements contract terms and conditions.
- Manages: Referral Manager; Referral Coordinator Team; On-site specialists; Social Workers; Case Managers.
- Other Responsibilities may include:
- Develops and implements new payment methodologies and provider incentives.
- Manages provider network costs, by ensuring appropriate coverage and minimizing extra payment costs.
- Ensures communication and resolution of provider issues to applicable team members and other departments.
- Identifies areas to improve provider service levels and quality.
- Coordinates an overall annual budget.
- Provides training and input across market staff on network and referrals strategies.
- Contributes as senior market leader to success of whole market performance.
- Contributes as senior company leader to sharing of best practices and identification of future potential innovations.
- Other duties as assigned and modified at manager’s discretion.
KNOWLEDGE, SKILLS AND ABILITIES:
- knowledge of national provider network.
- Excellent analytical and reasoning abilities.
- Excellent management skills.
- Excellent presentation, verbal and written communication skills.
- Experienced with Microsoft Office Tools.
- Ability to build and manage a team of diverse professionals.
- Ability to establish and maintain positive and effective work relationships with coworkers, clients, and providers.
- Knowledge of Medicaid/Medicare plans, federal and state legislation.
- Ability to travel on occasion for company meetings, contract negotiations and vendor management
- Excellent customer service skills.
- Team oriented.
- Ability to handle a fast-paced environment.
- Desirable: Knowledge of analytical software packages such as QlikView.
Additional Job Description
EDUCATION AND EXPERIENCE CRITERIA:
- Bachelor’s degree Business Administration or a closely related discipline required OR additional related work experience above the minimum will be considered in lieu of the required education.
- Master’s degree preferred.
- A minimum of 7 years building national provider networks.
- A minimum of 3 years of management experience.
- Experience in working with Insurance, Health Plans companies, and/or Independent Medical Clinics.
- Experience working in the healthcare industry.
- Experience in contract negotiation.
- Experience in clinical recruiting.