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Director,, Network and Medical Costs

  • R0005936
  • Miami / South Florida — Corporate Office III
  • January 10, 2019

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Job Description
The Director, Network and Medical Costss responsible for network growth and development, 1099, employment and agency recruitment and contract negotiations. The role is responsible to monitor operational performance, contractual compliance, recruiting, marketing, provider development, and contracting and provider relationship management. As a senior market leader, this position contributes to the success of market performance.

ESSENTIAL JOB DUTIES/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 manages 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. Identifies 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 the referrals team and process (review, process, authorization, follow-up and coordination with providers).
  • Creates and implements new service lines such as collaborative psychiatric care and emergency paramedic home visiting.
  • Conducts contract negotiations with individuals, agencies and national provider networks.  Implements contract terms and conditions.
  • 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.
  • Manages: Referral Manager; Referral Coordinator Team; On-site specialists; Social Workers; Case Managers.
  • Other duties as assigned and modified at manager’s discretion.

Other Responsibilities may include:

  • Develops and implements new payment methodologies and provider incentives.
  • Manages provider network costs; ensures appropriate coverage and minimizing extra payment costs.
  • Ensures communication and resolution of provider issues to applicable team members and other departments.
  • Supports communication and collaboration with health plans at a market level (e.g., coordinate joint operating committees).
  • 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.
  • Shares best practices and identification of future potential innovations with senior leadership.
  • Works collaboratively with PMR to support the development of a coordinated network strategy across MSO and staff center doctors as dictated by market needs.

KNOWLEDGE, SKILLS AND ABILITIES:

  • Excellent management, analytical and reasoning abilities; ability to work in a fast-paced environment
  • Excellent presentation, verbal and written communication skills
  • 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 develop and present RFP’s to potential providers
  • Ability to travel on occasion for company meetings, contract negotiations and vendor management
  • Excellent customer service and team-oriented skills with the ability to build and manage a team of diverse professionals
  • Desirable: Knowledge of analytical software packages such as QlikView
Additional Job Description

EDUCATION AND EXPERIENCE CRITERIA:

  • Bachelor’s degree OR an equivalent combination of directly related work experience and college-level coursework at a 2:1 ratio required. Masters preferred;
  • Minimum ten (10) years building national provider networks;
  • Minimum five (5) years of management experience;
  • Experience in working with Insurance, Health Plans companies, and/or Independent Medical Clinics;
  • Experience working in the health care industry, including clinical recruiting;
  • Experience in contract negotiation;
  • Experienced with Microsoft Office Suite.

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