Responsible for supporting the VP of Network Operations in the day-to-day operations of the Specialty Provider Networks (SPN) which the respective individual manages for Health Network One, Eye Management, and/or Therapy Network (collaboratively referred to as “HN1”).
- Support the VP of Network Operations in the management and operations of each market/state of his/her assigned SPN(s).
- Participate in Medical Expense Initiatiatives to support the adherence to a MLR of 85% or below for specialty networks.
- Support the VP of Network Operations and President of HN1 as the point person for any business development activities taking place within the Director’s service area and/or SPN.
- Support the VP of Network Operations in the development and administration of the goals and objectives set for the Specialty Provider Network(s) on both a market specific and overall companywide basis.
- Support the VP of Network Operations in maintaining oversight and responsibility for all needed internal training, training material and creation of and implementation of policies and procedures.
- Respond to health plan audits as required.
- Support the organization in meeting all SLAs related to Network Operations for our payer partners.
- Develop and maintain a close working relationship with the TPA operations staff and work interdependently with each Department: Claims, Utilization Management, IT, Credentialing, and Provider File Maintenance.
- Advise Senior Management of both strengths and weaknesses in the SPN and work with VP of Network Operations to institute or recommend changes which better serve the organization and its assigned membership.
- Act as a senior liaison between HN1 and Health Plans with all relevant matters concerning contractual, financial and operational terms as stated in HN1’s network agreements with Health Plans.
- Develop and maintain familiarity with the managed care industry, such as the availability of outside sources of information, statutes affecting HN1 business, current industry trends, and general services/locations of major non-contracted health plans and providers.
- Participate in the contributions to all staff and committee meetings as requested by the VP of Network Operations and/or President & COO, including evening quarterly Executive Committee Meetings (ECMs) and Medical Advisory Committee Meetings (MACs).
- Bachelor's degree (B.A.) or five (5) plus years senior management contracting/development experience.
- Two or three years extensive working background in the managed care industry.