Senior Director of Provider Network Operations

About the Role

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. The Senior Director of Provider Network Operations is accountable for the performance and experience of the MetroPlusHealth network, including 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 provider partnerships, excellent provider experience, accuracy of the provider directory, and optimal results with access and availability leading to positive member experiences.

Responsibilities

• Oversee the company’s Provider Data Management strategy.
• Improve the overall provider experience by soliciting feedback in the annual provider survey and acting on areas for improvement.
• Ensure 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.
• Use network performance data to identify and execute 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.
• Oversee 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 execute 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.

Requirements

• 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, or 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.

Skills

• 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