[Remote] Director Provider Network and Operations

Note: The job is a remote job and is open to candidates in USA. Community Health Options is focused on enhancing provider network management and operations. The Director of Provider & Network Operations will oversee network management, provider relations, and contracting while driving strategies for quality and financial viability.ResponsibilitiesResponsible for assuring the financial viability, overall service, and quality and performance of provider networksOversees the development and implementation of provider contracting strategies and provider contracting negotiations and ensures the terms of the contracts are fulfilledLeads provider contracting and servicing activities for business expansion. Develops and implements strategies to strengthen and/or develop new physician, hospital, and other provider relations. Defines provider network expansion requirements in new and existing geographic service areas, and for new lines of businessApproves and monitors special requests, retroactive adjustments, reimbursement, and contract exceptionsModifies networks, their composition, contracts, reimbursements, credentialing standards and utilization trends as needed to assure goals are metCollaborates with physicians and other organizations to develop and pursue mutually beneficial business opportunities to meet community needs for health care servicesMaintains access to a high quality geographically desirable cost-effective network of specialists, hospitals, and ancillary providers to meet the needs of members servedDirects the implementation of new health plan contracts/product lines which respect to the Provider Network Management responsibilitiesDirects rate analysis, scope assessment, and geographic coverage assessment prior to extending agreements to providers recruited to satisfy network needsOversees all primary IPA, Medical Group and Hospital market research to gain qualitative and quantitative data to bring definition to market strategiesOversees initiatives to engage with local or regional Accountable Care Organizations (ACOs)Monitors industry changes, trends, and events to proactively identify opportunities to increase market penetration and performance improvementOversees recruitment of providers for new networks; optimizes size and composition of existing networks, and other projects necessary to meet business performance and growth goalsEnsures network providers meet quality, cost, and coverage standards, and comply with applicable laws, regulations, and accreditation requirementsDevelops and manages team and corresponding budget as needed to assure successProvides strategic direction to lead network development to enable continued growth, profitability, and industry leadershipAssists with provider relations activities as neededCollaborates with internal teams including medical management, operations, and risk adjustment to align the network strategy with clinical and financial objectivesUpdate and interface with senior leadership team as appropriate on initiativesEnsure network providers meet quality, cost, and coverage standards, and comply with applicable laws, regulations, and accreditation requirementsOversees the determination and implementation of any health plan or regulatory corrective action plans related to provider network activitiesSkillsBachelor's degree is required and master's degree desirableMinimum 5 years of management experienceA minimum of 5 years' experience in provider contracting and provider relationsMust understand Medicare, RBRVS, case rate, capitation, and other related payment structuresCompany OverviewCommunity Health Options is a non-profit organization that provides health insurance benefits to individuals, families, and businesses. It was founded in 2012, and is headquartered in Lewiston, Maine, USA, with a workforce of 51-200 employees. Its website is https://www.healthoptions.org.