Community Health Options

Operations

• Responsible for assuring the financial viability, overall service, and quality and performance of provider networks.
• Oversees the development and implementation of provider contracting strategies and provider contracting negotiations and ensures the terms of the contracts are fulfilled.
• Leads provider contracting and servicing activities for business expansion.
• Develops and implements strategies to strengthen and/or develop new physician, hospital, and other provider relations.
• Defines provider network expansion requirements in new and existing geographic service areas, and for new lines of business.
• Approves and monitors special requests, retroactive adjustments, reimbursement, and contract exceptions.
• Modifies networks, their composition, contracts, reimbursements, credentialing standards and utilization trends as needed to assure goals are met.
• Collaborates with physicians and other organizations to develop and pursue mutually beneficial business opportunities to meet community needs for health care services.
• Maintains access to a high quality geographically desirable cost-effective network of specialists, hospitals, and ancillary providers to meet the needs of members served.
• Directs the implementation of new health plan contracts/product lines which respect to the Provider Network Management responsibilities.
• Directs rate analysis, scope assessment, and geographic coverage assessment prior to extending agreements to providers recruited to satisfy network needs.
• Oversees all primary IPA, Medical Group and Hospital market research to gain qualitative and quantitative data to bring definition to market strategies.
• Oversees initiatives to engage with local or regional Accountable Care Organizations (ACOs).
• Monitors industry changes, trends, and events to proactively identify opportunities to increase market penetration and performance improvement.
• Oversees recruitment of providers for new networks; optimizes size and composition of existing networks, and other projects necessary to meet business performance and growth goals.
• Ensures network providers meet quality, cost, and coverage standards, and comply with applicable laws, regulations, and accreditation requirements.
• Develops and manages team and corresponding budget as needed to assure success.
• Provides strategic direction to lead network development to enable continued growth, profitability, and industry leadership.
• Assists with provider relations activities as needed.
• Collaborates with internal teams including medical management, operations, and risk adjustment to align the network strategy with clinical and financial objectives.
• Update and interface with senior leadership team as appropriate on initiatives.
• Ensure network providers meet quality, cost, and coverage standards, and comply with applicable laws, regulations, and accreditation requirements.
• Oversees the determination and implementation of any health plan or regulatory corrective action plans related to provider network activities.

Director, Provider Network and Operations