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.
DEPARTMENT: Provider Relations/Network Management
REPORTS TO: Director, Network Management
- Manages the network for IPA's, primary care and specialty physicians and ancillary providers.
- Achieves company targets through aggressive IPA primary care, specialty and ancillary provider contracting and risk contract management.
- Manages physician network by developing and maintaining relationships to drive business results within a specific geographic area.
- Provides service and education to network physicians/providers.
- Conducts site visits to service providers, resolves issues, educates staff/providers on policies, collects credentialing information, and reviews HEDIS information.
- Supports regional Network Improvement Plan targets by providing utilization reports, pharmacy profiles, ER contingencies, Frequent Flier Reports and other analytics available to improve /maintain regions.
- Manages incoming provider inquiries: identifies potential claims trends and follow-up with provider and internal departments to ensure that identified problems have been resolved.
- Strategizes for membership growth and retention.
- Special projects as assigned or directed
- Bachelor's degree preferred or equivalent directly related Network Development or Provider Relations experience.
- 5 years experience in Provider Relations or Network Development.
- 3 years experience with managed care.
- IPA/Risk Contracting experience required.
Special Skills (e.g. 2nd language):
- Excellent influencing and negotiating skills.
- Ability to analyze and explain complicated financial terms and utilization data to physicians and staff.
- Excellent written skills.
- Excellent public speaking skills.
- Intermediate or stronger skill level with MS Word, Excel and Outlook required.