Directs and monitors the overall performance of provider network development and network performance responsibilities for Beacon Direct and its clients. Accountable for the development and implementation of accurate, timely and competitive contracts that reflect all applicable legislative and competitive standards. Develops and communicates provider network policies and procedures.
Participates in strategic planning, decision-making, short- and long-range goals, objectives and plans, and in the development and implementation of Beacon Direct business plans. In coordination with the Beacon leadership team, assists in in the development of network strategies on recruitment, contracting, reimbursement, risk and incentive programs, and network performance. As applicable, directs network expansion activities, including developing strategies for negotiation with new providers and provider networks.
Works directly with or coordinates matrix functions with (e.g. Claims processing, Credentialing, Medical Management, Care Management, Quality Management, Data Analytics and Data Services) critical to Network Management. Engages with relevant executives of provider organizations to negotiate and execute contracted arrangements, to develop business plans for ensuring success in value-based arrangements, and to encourage the provider organizations to focus on activities consistent with Beacon Direct strategies. They are also responsible for identifying opportunities to reduce cost, improve quality and enhance the patient experience of care while at the same time monitoring the results of these efforts.
Reports to: Vice President, Beacon Direct Services.
1.Exercise a matrix management approach to coordinate functional areas across Beacon Health and NLH to direct, manage and support the operations of Beacon Direct.
2.Develop and maintain a comprehensive provider network (hospitals, physicians, and ancillary services) to deliver a full range of health care services to Beacon Direct clients and their members through recruitment, negotiation, contracting and re-contracting of providers to ensure quality, cost effectiveness and their participation.
3.Analyze, plan and assure provider network adequately meets access needs across all geographic areas.
4.Negotiates fee for service and other arrangements for Beacon Direct and manages personnel and consultants in the functional area, manages a range of complex and sensitive activities required for an organized and effective provider network.
5.Assists with the development of strategic initiatives relating to provider networks, including service area expansions, new payment and incentive methods, risk arrangements and new service offerings.
6.Evaluation and recommendation of high value providers that should be added to the Beacon Direct network and contract with provider based on reputable data, and consistent with Beacon Health Leadership guidelines.
7.Foster the development and maintenance of purposeful, long term relationships with providers based on fair and competitive business terms, with an emphasis on improving quality and the patients' experience of care, while reducing the cost of care.
8.Participate in developing, communicating and implementing policies, practices, standards and programs that support the achievement of Beacon Health and NLH's goals, strategies, and objectives.
9.In collaboration with the Medical Director, monitors and shares cost, utilization and quality reports for key provider organizations.
10.Serve as the subject matter expect and key contact for consultation regarding the Beacon Direct Provider Network.
11.In collaboration with Medical Director and other Beacon leaders, periodically reviews the claims edits, prior-authorization and pre-certification rules as well covered and non-covered services and make recommendations for changes and implement these changes with all constituents.
12.Acts as provider advocate by communicating with appropriate Beacon Direct leaders and subcontractors regarding provider concerns
13.Maintain an up to date understanding of the Maine provider and payer market and provide advice to Beacon leadership on upcoming trends and initiatives.
14.Maintains enough knowledge of billing rules and regulations in order to assist in resolving billing issues.
15.In conjunction with Beacon staff and subcontractors maintain an accurate database of provider information and responsive reporting capabilities regarding contracting status and network development.
16.Prepares and conducts an ongoing orientation program to educate Beacon Direct participating provider network regarding Beacon Direct policies and procedures, reimbursement methodology, financial terms and concepts, product lines and associated benefit structure (s).
17.Identify and resolve service inquiries from participating provider network and other healthcare professionals. Assists Beacon personnel and claims processing in resolving contract disputes related to claims inquiry.
18.Represents Provider Network Management in the sales function for Beacon Health.
Build and maintain effective relationships with employers, plan members, brokers, providers, system leaders, other healthcare organizations, government and regulatory bodies and others.
Works closely and collaboratively with Beacon Health leaders, NLH Benefits leaders, and vendors to optimize both system and health plan performance.
Interface with NLH's delivery system and participating providers to assure appropriate processes that support the access to care for Beacon Health Plan members; and to ensure member-responsive and cost-effective health care.
Interface with NLH staff / departments to ensure collaborative relationships.
Evaluate and make recommendations regarding benefit plan design and benefit coverage for the Beacon Health Plan.
Participate in planning and outreach for new business opportunities for Beacon Health and work with appropriate team(s) to develop business plans to implement approved strategies.
SKILLS AND ABILITIES:
This candidate must be a self-starter, who is able to work in fast-paced dynamic environment. They must possess initiative to produce improvement initiatives both internally and with clients. The candidate must have excellent communication and customer service skills in order to maintain positive provider relations.
Ability to work across organizational boundaries with all levels of staff, including senior executives, directors, managers and professional staff. Must be a proactive leader with the ability to motivate others; decision making skills essential to resolve issues. Experience in a matrix style management organization.
Advanced knowledge of value based provider payment, utilization management and clinical programs along with good comprehension of these programs as they correlate with improved Triple Aim performance outcomes
Demonstrates ability to prioritize and maintain flexibility in changing priorities.
Demonstrates strong leadership, organizational, communication, and analytical skills.
Demonstrates strong communication skills and the ability to conduct presentations to providers and Health Plan administrative staff, including the ability to speak in public.
Demonstrates the ability to work independently exhibiting strong analytical and
problem solving abilities and negotiation skills.
Demonstrates ability to handle complex provider service issues.
Demonstrates understanding of health care delivery system, particularly physician
group practice issues. Exhibits comprehension of basic contract language and
regulatory requirements and knowledge of managed care principals.
Demonstrates proficiency with standard software (Excel, Word, Access, Outlook)
EDUCATION AND/OR EXPERIENCE:
Must possess a bachelor's degree in business administration or related field from an accredited institution.
Master's degree preferred
Minimum of 5 years experience with provider relations including provider/payor contract negotiations or practice operations required, with skills/knowledge abilities in managed care, payment methodologies and new market development. Knowledge or experience in Commercial Health Plans required and experience with Medicare Advantage Plans a plus. Additional experience in one of more of the following areas is preferred: Employer/Self-Insured Health Plans, Medicare, Medicaid, and Integrated delivery Systems.
Proven ability to handle complex provider service issues.
Experience in interpreting benefits available to members/patients and provider/payor networking
Experience administering healthcare and pharmacy benefits for healthcare systems a plus.
Experience in ACO arrangements or related risk-sharing arrangements in health care a plus.
Knowledge of ICD-9/10 and CPT coding a plus.
Valid driver's license required.
WORKING CONDITIONS/PHYSICAL DEMANDS:
Work is typically performed in an office environment. Willingness to travel
approximately 60 percent of the time. Must be willing to accept occasional overnight
travel assignments. May require evening and weekend work hours. Independent
travel to sites throughout the system and surrounding communities may be required.
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.