Manages physician contracting, network development and provider relations functions for developing, executing and maintaining a provider network strategy. Works in concert with medical management and sales developing actions to meet market growth and medical cost targets. Provides service and education to network physicians/providers.
Reports To: Sr., Director, Network Management
Department: Network Management
Position Location: Columbia, SC 29210
- Leads a team of Network Management Representatives and/or Specialists in developing, servicing and contracting providers.
- Achieves company targets through aggressive IPA primary care, specialty and ancillary provider contracting and risk contract management.
- 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.
- Assists in developing practices to assist risk partners in managing financial risk.
- Identifies areas to improve provider service levels.
- Educates/enhances relationships within the provider community.
- Special projects as assigned or directed
Education: A Bachelor's Degree in a related field or equivalent related Network Development or Provider Relations experience.
Experience: 7 years of work experience in the healthcare sector (preferably at HMO or PPO). 5 years experience in HMO provider/hospital/ancillary contracting and network development. 3 years of progressively responsible managerial experience. Strong knowledge of regulatory requirements concerning Medicare and Medicaid.
Special Skills (e.g. 2nd language):
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
Organized, disciplined, hands-on and process-oriented leader