Director - Network Development

Responsibilities

• Manage and negotiate contracts in compliance with HCS reimbursement standards.
• Aid and implement provider contracting policies and procedures that align with industry best practices and regulatory requirements.
• Ensure accurate implementation of contracts and collaborate with other departments for contract and special arrangement reporting, provider database maintenance requests, and new hospital implementation.
• Conduct research, identify root cause analysis, and work fall out reports causing operational deficiencies.
• Manage the maintenance of all provider contract language and templates and ensure that all negotiated contracts can be configured into the HCS systems.
• Collaborate with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation, and business requirements.
• Responsible for accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance across all lines of business.
• Coordinate across network management for the submission of hospital, ancillary, and professional rate loads, pricing configurations, and contract storage.
• Manage the effectiveness and efficiencies of operations which includes management of contract inventory and adherence to all regulatory requirements and internal policies and procedures.
• Understand the impact of provider contract provisions on claims payment accuracy and timeliness and present solutions to minimize unnecessary deviation and support auto-adjudication.
• Understand the credentialing and recredentialing process, provider directory maintenance, and regulatory standards.
• Collaborate across departments to ensure that provider services are aligned with the needs of claimants and the organization.
• Assist with keeping the provider network integrated with the organization’s objectives.
• Provide management level leadership and support all of the contracting staff.
• Develop and train staff; develop and monitor goals; conduct annual performance reviews.

Qualifications

• Bachelor’s degree required. Master’s degree preferred in Business, Healthcare Administration, or Public Health or relevant experience in lieu of degree in health or health care related field.
• Minimum 10 years demonstrated business experience in hospital and provider group finance and/or managed care network development.
• Minimum 10 years in-depth knowledge and understanding of contract finance and reimbursement methodologies including FFS, Workers Compensation/PIP pricing, and incentive arrangements.
• Minimum 10 years prior provider experience in a healthcare setting including but not limited to Workers Compensation, PIP, Commercial, and/or Value Based Programs is required.
• Minimum 5-8 years’ experience in health care cost data analysis.
• Minimum 5-8 years supervisory experience and/or leading people by influence.