Dir Network Mgrm Ops Job in Albuquerque 87101, New Mexico Us

The Director of Network Management and Operations will plan, organize, staff, and coordinate all activities of the state Provider Network Management Department. Works with staff and Senior Management to develop and implement provider contracts, contracting and provider service strategies. Also is the primary plan liaison for Claims, Member Services and other Corp. Departments.

 

Education

Required:

Bachelor’s degree required in a related field (Business Administration, etc.,);

Master’s degree preferred.

Experience

Required:

·         7-10 years minimum experience in Healthcare Administration, Managed Care, and/or Provider Services.  

·         Experience managing/supervising employees preferred.  Superior verbal and written communications skills.  

·         Exceptional interpersonal relations skills. Ability to organize, coordinate and accomplish a high volume of work with minimum impact on quality. 

·         Superior interpretation and research skills in order to readily identify problems, and get to the root cause and achieve prompt resolution to problems and issues. Includes analytical skills. 

·         Knowledge of Excel and Word

·         Demonstrated adaptability and flexibility to changes and response to new ideas and approaches.

 

DUTIES AND RESPONSIBILITIES

 

•       Develop and implement provider network and contract strategies, identifying those specialties and geographic locations on which to concentrate resources for purposes of establishing a sufficient network of Participating Providers to serve the health care needs of the Plan’s membership.

•       Develop and maintain a market Provider Reimbursement Strategy consistent with Reimbursement Tolerance Parameters (across multiple specialties/ geographies). Oversee the development of new reimbursement models. Develop and maintain a system to track Contract Negotiation activity on an ongoing basis throughout the year.

•       Direct the preparation and negotiations of provider contracts and oversee negotiation of contracts in concert with established company guidelines with physicians, hospitals, and other health care providers.

•       Contribute as a key member of the Senior Leadership Team and other committees addressing the strategic goals of the department and organization.

•       Oversee the maintenance of all Provider contract information, Provider Contract Templates and assure that all contracts negotiated can be configured in the QNXT system. 

•       Work with legal on an as needed basis to modify contract templates to ensure compliance with all contractual and/or regulatory requirements.

•       Fee schedule management

•       Develop strategies to improve EDI/MASS rates

•       Oversight of the Provider appeals and grievance process

•       Accountability for Delegation Oversight

•       Provider problem research and resolution, provider services, joint operating committee management

•       Coordination with enrollment growth to ensure that Molina grows faster (profitable growth) than our competitors in key provider practices

•       Complies with required workplace safety standards.

•       Adheres to the company and/or departmental confidentiality standards and HIPAA compliance programs.

•       Adheres to the company and/or departmental fraud and abuse prevention/detection policies and programs.

Molina Healthcare is an Equal Opportunity Employer (EOE). M/F/V/D