Director, Provider Network Management

Summary of Job

Responsible for ensuring overall network compliance with all Plan and regulatory requirements, the processing and management of all provider and vendor contracts, oversight and management of provider directory production.  Lead the operational redesign and implementation of priority network projects.  Responsible for the development and implementation of department-wide operational process guidelines.  Meet regularly with Legal, Corporate Compliance, and Product Regulatory leadership to share information and discuss issues impacting Provider Network Management.  Responsible for ensuring overall network compliance with all Plan and regulatory requirements, the processing and management of all provider and vendor contracts, oversight and management of provider directory production.  Lead the operational redesign and implementation of priority network projects.  Responsible for the development and implementation of department-wide operational process guidelines.  Meet regularly with Legal, Corporate Compliance, and Product Regulatory leadership to share information and discuss issues impacting Provider Network Management

Responsibilities 

Network Compliance:

• Provide regulatory leadership and guidance for Network Management activities; operationalizing actions to conform to regulatory requirements. 
• Establish and maintain mutually beneficial relationships with regulatory contacts. 
• Ensure timely responses to regulatory agencies (i.e. NYSDOH, DFS) in response to all network regulatory and compliance inquiries; developing, implementing, and monitoring plans of correction when applicable. 
• Represent Provider Network Management at internal/external regulatory audit interviews. 
• Manage the NYSDOH mandated Hospital/IPA Closure and Termination process. 
• Represent Provider Network Management in all enterprise compliance and regulatory activities such as the Monthly Compliance Committee, Regulatory Compliance Committee, and NCQA Accreditation; leading and implementing any and all initiatives impacting Provider Network Management. 
• Manage and coordinate the timely distribution of all regulatory provider incentives (i.e. QIVAPP). 
• Collaborate with enterprise functional areas to improve processes and communications (i.e. delegation oversight). 

Provider Contract Management:

• Ensure all contracts and implementations are reviewed for compliance with current Provider Contracting Guidelines, 
• processed within department service levels and routed to the appropriate contract configuration staff. 
• Overall responsibility and oversight of enterprise contract repository to include but not limited to assurance of data integrity and monitoring security and access to same. 
• Responsible for security and maintenance of paper contract files. 
• Responsibility for fulfillment of requests for copies of contracts from internal/external customers. 
• Actively participate in all workgroups in which the Provider Network Management Contract Management department is a stakeholder.

Provider Network Redesign:

• Lead the operational redesign and implementation of priority network projects. 
• Partner with business areas throughout the organization to identify areas of opportunity. 
• Develop work plans and execute plans accordingly. 

Provider Directory Production:

• Ensure directories are produced within the required timeframes. 
• Collaborate with business areas to determine and document the directory requirements. 
• Supervise and ensure the development of business requirements for directory production and liaise with the directory production vendor to ensure all requirements are programmed and developed. 

Policy/Workflow Development, Training, and Implementation:

• Responsible for development and implementation of policies, procedures, and workflows for all of Network Management. 
• Ensure annual review of all Network Management operational process guidelines. 
• Educate Provider Network Management department on all and new and revised policies, procedures, and workflows. 
• Identify training needs within the Provider Network Management Department; coordinating training and developing materials to support same.

Six Sigma/Lean Process Improvement Initiatives

• Contributes with department wide process improvement initiatives suc as leading Lean, Six Sigma Black Belt, and other special projects. 
• Identify areas for improvement and make recommendations to Senior Leadership. 
• Participate in process improvement initiatives in the organization as representative of Provider Network Management.