Overview

Provides management oversight to the department in the development and maintenance of positive relationships with the participating physicians, facilities, home-based and ancillary providers. Develops, , manages and monitors the relationships with various provider types including but not limited to hospital, ancillary, home-based providers, physicians and IPAs (Providers) to enhance the level of service to those providers and our members to increase quality performance and reduce administrative burdens. Ensures Providers receive adequate orientation and education in-services and troubleshoots/resolves related issues. Works under general supervision.

Responsibilities
Manages and tracks the annual regulatory Model of Care training to network Providers which includes management policies, procedures and operational systems for the Medicare/Dual eligible population.Interfaces/collaborates with Plan staff to monitor Provider performance, identify unmet service needs and operational issues.  Investigates staff/member and Provider complaints, identifies trends, reports findings, recommends action and supports resolution, as necessary.Collaborates with department leadership regarding Provider capacity and network adequacy monitoring, regional needs assessments and identifying potential Providers for recruitment into program.  Manages or assists with department or plans special projects.Keeps abreast of current industry trends, governing regulations, reimbursement practices and market competition.  Keeps Plan management informed of trends/changes and makes recommendations based on this information.    Collaborates with Sales, Quality, Pharmacy and various departments to create opportunities and introduce providers to respective individuals within those departments.  Coordinates/participates in training of Account Managers and staff in other departments.  Sets daily, weekly, monthly and annual Provider site visit targets and ensures they are being met.  Identifies common issues affecting Provider networks and works with Account Managers and health plan colleagues to develop solutions.  Accompanies Account Managers on-site visits to ensure the team is meeting performance standards. Conducts Provider Satisfaction Surveys annually or as implemented by department management and assists to address identified issues.Manages the Account Managers in the maintenance of relationships and monitoring of performance for the Plan’s Provider networks to enhance level of services for plan members and providers.  Performs and documents Provider site visits, communications and attends events/activities/forums to strengthen relationships with Providers.   Investigates, troubleshoots and resolves Provider complaints or other issues.Manages the on-boarding and orientation of new Providers and implements the operational relationships between Plan and Providers. Ensures that Providers are oriented and updated on Plan program policies and procedures.  Develops tools to determine effectiveness of orientation, in-service process and implements changes/improvements, as required.Develops relationships with Independent Physician Associations (IPAs), group practices, individual physicians, hospitals, health systems, ancillary and home-based providers to develop and maintain positive working relationships and foster wholesale marketing channels and innovative medical management strategies. Works with and supports other VNSNY CHOICE (Plan) departments to facilitate the exchange of information with Providers, utilization IPA reporting.Ensures all department policies and procedures are reviewed annually, updated as necessary and remain in accordance with State, CMS or other regulatory requirements as applicable.Collaborates with Sales, Quality Management, Pharmacy and various Plan departments to create opportunities and introduce providers to respective individuals within those departments and increase membership.Collaborates with the Credentialing Subcommittee and program staff in quality assurance monitoring and evaluation of network Providers.  Evaluates/analyzes findings from audits and works with appropriate staff to develop/implement corrective plans of action. Provides feedback to Providers, as needed. Prepares Provider network adequacy analyses to ensure regulatory requirements and member needs are fulfilled and support Provider recruiting and contracting needed to fill identified network gaps and network expansion.Support Plan’s Quality and Risk departments efforts to increase quality scores based on state specific quality measures.Assist the Credentialing staff with initial and re-credentialing process for contracted Providers. Conducts audits for in-network Providers with delegated credentialing responsibilities and ensures required documentation is up to date.  Follows-up with Providers to investigate/resolve re-credentialing issues and communicates with Credentialing Committee and senior management, as necessary.Performs all duties inherent in managerial role.  Recommends hiring, performance appraisals, promotions, termination and performs orientation/training to facilitate the professional growth and development of assigned staff.Performs other related duties, as assigned or requested. Manages and leads the ongoing Provider communication forums and Joint Operating Committees to address operational concerns and identify/evaluate/implement programs or policy/procedure improvements that benefit both the Provider and Plan.Develops clinically oriented Provider and community-based partnerships and supports the Quality Department in order to increase quality scores based on state and CMS specific quality measures. Coordinates with and supports the Risk Department with Provider education and medical record collection in order to accurately reflect member RAF scores.Manages the introduction/establishment of the provider within VNSNY internal systems.  Serves as key liaison between Providers and internal systems to ensure disclosure of requisite information, positive image of VNSNY, carry through of any follow-up and smooth/effective contract development. Manages the orientation of new providers and implements the operational relationships between providers and plan. Ensures that providers are oriented and updated on Plan policies and procedures.  Develops measurement tools to determine effectiveness of orientation, in-service process and implements changes/improvements, as required.
Qualifications

Education: 

Bachelor’s degree in Health Administration, Business Administration or related discipline required.  Master’s degree preferred.

Experience for Provider Relations:

Minimum five years in managed care or provider back-office required.  Experience working in healthcare administration and/or operations required. Experience working with healthcare providers as customers or clients required.  Comprehensive understanding of provider network contracting required.  Minimum of two years managerial experience preferred.  Experience in marketing and public relations in a health care or related environment preferred.