Senior Director of Provider Network Operations

MetroPlus; New York (NY); On-site; USD 150,000 - 220,000; Full time

Job summary

MetroPlusHealth in New York is seeking a Senior Director of Provider Network Operations to oversee the performance and experience of the provider network. You will lead data management, directory accuracy, regulatory compliance, and provider communications, driving high-quality partnerships and optimal access for members.

You will guide a team, define strategies to improve reimbursement, directory reliability, and patient experiences while collaborating with senior leadership on regulatory

Qualifications

• Data management, data analytics, quality assurance, and project management skills required.
• Working knowledge of Medicare and Medicaid required.
• Ability to standardize and reconcile disparate data effectively.

Responsibilities

• Oversee Provider Data Management strategy and provider directory accuracy.
• Improve provider experience by collecting feedback and acting on improvements.
• Ensure quick resolution of issues related to reimbursement, directory information, and patient experience.
• Identify efficiency improvements and recommend automated solutions.
• Use network performance data to boost financials, quality, risk adjustment, and growth.
• Collaborate with Senior Leadership and committees on strategic goals.
• Monitor network adequacy to meet regulatory guidelines.
• Ensure regulatory compliance of access and availability standards and vendor oversight.
• Lead provider data accuracy initiatives and discrepancy resolution.
• Review reimbursement trends and reduce claims discrepancies.
• Partner with other functions on strategic planning and acquisitions.
• Manage and develop the team with a culture of accountability.

Skills

Integrity & Trust

Customer Focus

Functional/Technical Skills

Leadership

Communication Skills

Education

Bachelor’s degree in business or healthcare

Master’s degree preferred

Job description

Position Overview:

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

The Senior Director of Provider Network Operations is accountable for the performance and experience of the MetroPlusHealth network. This includes performance monitoring, operations, management and accuracy of provider directory, data, regulatory compliance, communications and training. Success in this role will be measured by high-performing and successful provider partnerships, ensuring excellent provider experience, accuracy of our provider directory and optimal results with access and availability leading to positive member experiences.

Scope of Role & Responsibilities:

• Oversee the company Provider Data Management strategy
• Improve the overall provider experience by soliciting feedback in the annual provider survey and acting on areas for improvement.
• Ensuring quick and complete resolution of issues relating to reimbursement, directory information, and the overall patient experience.
• Seek continuous improvement of operational efficiency, recommending automated solutions, and operational analyses to identify areas of improvement.
• Using network performance data, identify and execute on strategies to improve company performance on financials, quality, risk adjustment, member retention and growth activities.
• Contribute as a key member of the Senior Leadership Team and other committees addressing the strategic goals of the department and organization.
• Monitor and assess network adequacy to meet federal and state regulatory guidelines.
• Ensure regulatory compliance of provider access and availability standards, including oversight of vendor activities.
• Oversight of provider data accuracy, including vendor activities and the resolution of discrepancies resulting in a more accurate directory and reduced claims issues.
• Review network reimbursement issues, trends, and root cause analysis and executing on strategies to reduce claims payment discrepancies.
• Collaborate with internal functions on business analyses, strategic planning, implementation of new business acquisitions and changing corporate requirements.
• Manage and lead the team, assisting with their individual success, fostering a culture of accountability, collaboration, and continuous improvement.

Required Education, Training & Professional Experience:

• Bachelor’s Degree in Business Administration, Healthcare, or any analytical field required; Master’s Degree preferred.
• Minimum of 7 years of combined network management, credentialing, or regulatory affairs experience, operations, claims preferably in a managed care or insurance environment.
• Data management, data analytics, quality assurance, and project management skills required.
• Working knowledge of Medicare and Medicaid required.
• Ability to efficiently standardize and reconcile disparate data effectively.

Licensure and/or Certification Required:

• NONE

Professional Competencies:

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Strong leadership attributes and the ability to manage both individuals and multiple high priority initiatives
• Effective oral, written, and interpersonal communication skills required.