Network Manager, Ancillary Position

6 days ago

Orange, California, United States Alignment Healthcare Full time

Job Summary:

The Network Management Manager is responsible for contracting with all provider types and ensuring successful provider network performance related to key financial, operational, and member satisfaction performance indicators.

Works closely with other departments to enhance the contracted provider experience consistent with company's mission statement and values.

Key Responsibilities:

  • Responsible for the overall performance of the network within a designated region and for assuring that the day-to-day operations of the provider network are consistent with standards/ expectations.
  • Negotiate / re-negotiate and finalize all assigned contracts which may be primary care, specialist, ancillary, hospital, group/IPA as well as ensure the accuracy of administration of these agreements.
  • Develop agendas and lead regularly scheduled Joint Operations Meetings to drive results, including oversight of New Provider Orientations and new Contract Orientations.
  • Ongoing meetings will focus on addressing performance improvement metrics, resolving operational issues, including but not limited to utilization management, financial, enrollment, member appeals and grievances, provider termination/panel closures, continuity of care, and marketing activities.
  • Responsible for the execution of regional work-plans, monitoring performance metrics, updating status, and communicating progress both internally and externally to ensure results.
  • Responsible for overseeing physician adds and successful completion of physician credentialing, and NOC process for physicians adds.
  • Acts as technical resource on provider relations issues and offers strong, collaborative leadership internally as well as externally.
  • Responsible for timely and professional interaction with internal and external customers.
  • Interpret company policies and procedures.
  • Ensure accurate and timely data reporting requirements are being met for designated regions, including but not limited to provider network contacts, eligibility and capitation reports, risk sharing, claims timeliness, pharmacy utilization, bed day utilization, encounter data and audit compliance.
  • Develop goals and objectives that align with Network Management leadership's performance metrics to ensure department KPIs are met, as well as the organization's vision for future growth and network development.
  • Utilize contracting knowledge for effective problem resolution and compliance.
  • Responsible for timely and professional interaction in response to grievances.
  • Research, analyze and resolve complex problems dealing with hospital shared risk pool, claims, appeals, and eligibility issues within the appropriate limits.
  • Represents the department in interdepartmental meetings and selected committees.

Requirements:

  • Minimum 5-7 years' experience with an HMO, managed care provider organization (IPA, Medical Group or institutional provider) or insurance company with at least 3 years' specific experience in managed care contracting and knowledge or Medicare Advantage regulatory guidelines.
  • Proficient in MS Office, including strong Word and Excel proficiency.
  • Bachelor's Degree or equivalent experience required.
  • Detail oriented.
  • Ability to read and interpret documents such as contracts, safety rules, operating and maintenance instructions and procedure manuals.
  • Ability to interpret government regulations a must.
  • Ability to write routine reports and correspondence.
  • Ability to speak effectively before groups of providers or employees of internal/external organization.
  • Ability to calculate figures and amounts such as fee schedules, per diem rates, discounts, interest, commissions, proportions, and percentages.
  • Ability to apply concepts of algebra, geometry and statistics.
  • Strong analytic and problem-solving skills required, including ability to synthesize, interpret and apply detailed and complex information.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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