What are the responsibilities and job description for the Senior Vice President - Provider Network Operations & Contracting position at CareNational?
SENIOR VICE PRESIDENT – PROVIDER DELIVERY SERVICES
IN OFFICE POSITION – 60 MINUTES SOUTH OF PITTSBURGH IN WEST VIRIGINIA (Relo Assistance will be provided)
Position Summary
The Senior Vice President, Provider Delivery Services is accountable for provider contract development, provider education and provider network operations for the companies current service area and expansion areas and products. Create and communicate vision for provider payment innovation strategies and execution of value based / alternative payment models. Assure onboarding (credentialing, recredentialing, provider pricing configuration and provider directory accuracy) of practitioners, facilities, and ancillary providers is compliant with National Committee for Quality Assurance (NCQA), Center for Medicare & Medicaid Services (CMS), West Virginia Mountain Health Trust (WV MHT), West Virginia Office of the Insurance Commissioner (WV OIC) and/or Ohio Department of Insurance (ODI), and other states as applicable. Oversee the provider education and communication process, including bi-weekly “Core Communications,” quarterly “Provider Newsflash” and ad hoc provider messaging. Lead the provider servicing team to strengthen provider relationships through onsite visits and developing technologies to better support providers (on demand office orientations, provider podcasts and a robust provider portal). Responsible strategic hospital and health system executive relationships. Support the company’s TPA business by overseeing national networks and supporting self-funded network access. Assure compliance with NQCA, CMS, WV OIC, ODI regarding provider network adequacy and provider directory accuracy, and provider attestations to directory accuracy.
Essential Functions And Responsibilities
IN OFFICE POSITION – 60 MINUTES SOUTH OF PITTSBURGH IN WEST VIRIGINIA (Relo Assistance will be provided)
Position Summary
The Senior Vice President, Provider Delivery Services is accountable for provider contract development, provider education and provider network operations for the companies current service area and expansion areas and products. Create and communicate vision for provider payment innovation strategies and execution of value based / alternative payment models. Assure onboarding (credentialing, recredentialing, provider pricing configuration and provider directory accuracy) of practitioners, facilities, and ancillary providers is compliant with National Committee for Quality Assurance (NCQA), Center for Medicare & Medicaid Services (CMS), West Virginia Mountain Health Trust (WV MHT), West Virginia Office of the Insurance Commissioner (WV OIC) and/or Ohio Department of Insurance (ODI), and other states as applicable. Oversee the provider education and communication process, including bi-weekly “Core Communications,” quarterly “Provider Newsflash” and ad hoc provider messaging. Lead the provider servicing team to strengthen provider relationships through onsite visits and developing technologies to better support providers (on demand office orientations, provider podcasts and a robust provider portal). Responsible strategic hospital and health system executive relationships. Support the company’s TPA business by overseeing national networks and supporting self-funded network access. Assure compliance with NQCA, CMS, WV OIC, ODI regarding provider network adequacy and provider directory accuracy, and provider attestations to directory accuracy.
Essential Functions And Responsibilities
- Create annual Provider Delivery Services plan in collaboration with the President & CEO and in concept with the Executive Management Team.
- Directs the provider contracting negotiations, oversees established company templates and contract language guidelines with physicians, hospitals, and other health care providers and personally negotiates material health system contracts.
- Directs the provider servicing team to develop and grow provider relationships across the primary service areas
- Develops and implements provider network and contract strategies, identifying those specialties and geographic locations on which to concentrate resources for purposes of establishing a sufficient network of Participating Providers to serve the health care needs of the company’s membership.
- Develops and implements alternative payment methodologies including value and quality-based relationships and provider incentives.
- Implementation of an efficiency and clinical driven report card to drive network development and contracting
- Using data analysis tools to lead a strategy for partnership opportunities and healthcare integration
- Leads assigned negotiations (hospitals, physician and ancillary) and ensures the negotiations result in the unit cost targets and meet the objectives of the company.
- Evaluate and monitor providers’ performance standards and financial performance of contracts
- Contribute as a key member to Executive Management in the formulating and administering of company Policies and developing long-range goals and objectives.
- Maintains a database of industry data including but not limited to service areas, reimbursement mechanisms, product development and market share
- Oversee Provider Service and Engagement functions including education, claims reprocessing, contract interpretations, site visits, communications and general provider services.
- Serves as the company’s public liaison regarding provider-based activities.
- Oversee credentialing activities including practitioner credentialing, facility credentialing and delegated credentialing activity consistent with NCQA and government requirements.
- Oversees the development of new reimbursement models.
- In coordination with the Vice President of Sales and Marketing as well as identified corporate objectives, develops and monitors strategic network relationships regarding secondary support, extended area and self-funded access networks while maintaining quality, cost management and business development objectives
- Provides oversight of the Provider Fee Schedule Administration area including: entry and set up of fee schedule, capture and implementation of government terms and analyses of contracts and payments to ensure accurate configuration for claims payment as set forth in Claims Compliance Policies.
- In partnership with the Chief Medical Officer and other medical directors, provides strong leadership in implementing initiatives and strategies to control medical costs to achieve budgeted medical cost targets. This should occur through support of state-of-the-art provider contracts which incorporate the principles of performance accountability, effective medical management strategies, use of health information technology systems and implementation of a process of continuous improvement in care delivery.
- College degree and ten years industry related experience and/or training, or equivalent combination of education and experience.
- Sales and marketing experience.
- Experience in implementing new systems and programs.
- Ability to work with a variety of departments, employees, vendors and brokers.
- Ability to define problems, gather and analyze data, establish facts, and draw valid conclusions.
- Writing, verbal, and interpersonal skills.
- Able to give verbal presentations in a group setting.
- Knowledge of Microsoft Office programs.
- Able to travel frequently with overnight stays.
- Master’s Degree in a related field.
- 10 years of experience in a combination of insurance and health system administration.
- Strong analytical background.
- Healthcare contracting and negotiating experience.
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