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.
Department:Medicare, Provider Relations
Reports to:VP, Medicare Executive Director
Location: Brentwood, TN
- 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.
- Required A Bachelor's Degree in Business, Healthcare or related field
- Preferred A Master's Degree in a related field
- Required 7 years of experience in healthcare sector (preferably at HMO or PPO)
- Required 5 years of experience in HMO provider/hospital/ancillary contracting and network development
- Required 3 years of management experience
Licenses and Certifications:
- Intermediate Demonstrated organizational skills
- Intermediate Demonstrated leadership skills Disciplined, hands-on and process-oriented leader
- Advanced Other Knowledge of regulatory requirements concerning Medicare and Medicaid
- Advanced Other Knowledge of provider contracts and health care reimbursement
- Intermediate Other Understanding of regulatory compliance management and reporting requirements
- Intermediate Other Ability to manage complex transaction and service models
- Intermediate Other Demonstrated proficiency in establishing and driving medical cost management programs
- Intermediate Other Ability to negotiate effectively with internal/external stakeholders, large hospital and physician healthcare systems
A license in one of the following is required: