Sr Director, Network Management - Medicaid LOB

Directs a team in managing physician contracting, network development, provider relations and provider operations. Develops, executes and maintains a provider network strategy. Works in concert with medical management and sales to develop strategies to meet market growth and medical cost targets. Provides service and education to network physicians/providers.

Essential Functions:

  • Leads a team of department managers in developing and executing strategic departmental initiatives.
  • Achieves company targets through aggressive IPA primary care, specialty and ancillary provider contracting as well as risk contract management.
  • Manages required Hospital Contracting as appropriate.
  • Monitors primary care and specialty risk arrangements for Medicaid, and Medicare product lines.
  • Performs data analysis and develops specific actions to manage medical cost trend.
  • Develops best practice to assist risk partners in managing financial risk.
  • Identifies areas to improve provider service levels.
  • Educates/enhances relationships within the provider community.
  • Manages Network integrity and compliance.
  • Manages claims projects as necessary/required.
  • Manages provider loads as necessary/required.
  • Special projects as assigned or directed.

This position is contingent upon the bid award in the state of Texas to WellCare Health Plans, Inc.*LI-SM1

Education:
  • A Bachelor's Degree in Business, Healthcare, related field required or equivalent work experience
  • A Master's Degree in a related field preferred.
Experience:
  • 10 years of experience in healthcare sector (preferably at HMO or PPO) required.
  • 7 years of experience in HMO provider/hospital/ancillary contracting and network development required.
  • 5 years of management experience required.

Special Skills:

  • Demonstrated organizational skills.
  • Demonstrated leadership skills.
  • Disciplined, hands-on and process-oriented leader.
  • Knowledge of regulatory requirements concerning Medicare and Medicaid.
  • Knowledge of provider contracts and health care reimbursement.
  • Understanding of regulatory compliance management and reporting requirements.
  • Ability to manage complex transaction and service models.
  • Demonstrated proficiency in establishing and driving medical cost management programs.
  • Ability to negotiate effectively with internal/external stakeholders, large hospital and physician healthcare systems.

Technical Skills:

  • Intermediate proficiency in Microsoft Outlook, Word, Excel and PowerPoint.
  • Knowledge of and/or ability to utilize a budgetary software application.

About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.