Director Provider Network Management - HAP

The Director, Provider Network Management (PNM) with Health Alliance Plan (HAP), will be responsible for provider contracting and management of provider relations for assigned accounts using a coordinated team approach including the Director, and contract and provider services administrators. HAP’s focus is to move providers into alternative payment model (APM) contracts that reward HAP and providers for managing cost, quality and the member experience. Our PNM Directors then help providers maximize the value of APM contracts to realize total cost of care (TCOC) incentives, quality and other bonuses, TCOC budgets that recognize member medical demand through appropriate risk score recognition, general performance improvement initiatives (e.g. leakage avoidance) and member growth.

The Director is responsible for developing the strategic direction for regional markets under their supervision, generating data driven recommendations for provider strategic relationships and direction of key operations related to network development, physician/hospital contracting, APM contracts, provider services and improving network performance within a defined market. The Director will lead a team and identify opportunities for reducing the cost of care, achieving desired quality results using Medicare Star, Medicaid and HEDIS, cost containment and member satisfaction. Through leadership to direct staff, the Director will engage employees, manage performance, growth and development.

 Principal Duties and Responsibilities:

• Expand in network physicians and hospitals in alternative payment methods defined by the PNM VP.
• Develops and executes new value based contracting models
• Develops and executes programs across the continuum of alternative payment methods.
• Develops along with Plan Executives the quality programs supporting STARS and other corporate quality initiatives.
• Responsible for end-to-end management of provider relationships for designated accounts including contracting, onboarding, claims processing configuration data preparation based on negotiated contracts, provider performance improvement and strategic relationship development.
• Develops, negotiates, and implements provider contracts including, APM contracts with key provider groups. Leads contract preparation, devises objectives and strategy, manages negotiation within prescribe timelines, and documents contract terms with the assistance of legal counsel and other business unit subject matter experts.
• Oversees claims processing configuration data preparation for negotiated contracts and coordinates activities with Provider Reimbursement and Business Configuration Team to support contract implementation. Executes data quality control and hygiene activities to assure collection of high-quality data.
• Directly works with PHOs/POs/IPAs/Clinically Integrated Networks (collectively APM Entities or APMEs) to secure provider performance improvement including HEDIS, Medicaid and Medicare Star rating program, risk adjustment data collection, high performing provider referral management and leakage avoidance, total cost of care management (TCOC) s, and documentation of the data exchange and actionable information workflow with APMEs to support APM operations and performance improvement.
• Responsible for developing strategic partner relationships after evaluation of market alternatives and with a clear plan to realize value for HAP, including member growth.
• Cultivate accountable relationships between key leaders in the network and within HAP. Functions as a liaison between operational leadership within HAP and APME administrative staff and physicians to ensure positive provider working relationships are established and maintained.
• Use actionable information to drive HAP and provider performance. This requires the ability to meet each group where they are in the continuum of APMs. Continually identifies opportunities for provider performance improvement and supports APME efforts to achieve results with relevant information and metrics. Identifies HAP support needed to ensure success.
• Assess value-based risk readiness of all providers/facilities.
• Monitor financial, quality, member experience and member growth results for the APMs, and coordinates financial reconciliations and incentives with finance department. Communicates results to groups consistently and periodically as needed. Adept at understanding reports and actionable information to guide provider performance improvement.
• Develop and maintains purposeful long-term partnerships based on fair/competitive business terms, centered on improving the delivery of care and creating mutual rewards based on performance that result in in improvements in cost, member satisfaction and outcomes.
• Work with external resources to oversee event planning for physician focused events, relative to provider education, physician recognition and community-based provider educational initiatives.
• Performs other related duties as assigned.