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.
- 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 New Mexico to WellCare Health Plans, Inc.*LI-SM1Education:
- A Bachelor's Degree in Business, Healthcare or related field required.
- A Master's Degree in a related field preferred.
- 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.
- 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.
- Intermediate proficiency in Microsoft Outlook, Word, Excel and PowerPoint.
- Knowledge of and/or ability to utilize a budgetary software application.