Director, Provider Network Management

Program 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 :

Provider Network Redesign :

Provider Directory Production :

Policy / Workflow Development, Training, and Implementation :

Six Sigma / Lean Process Improvement Initiatives

Qualifications :

Additional Information