Director – Provider Network Operations – HAP – Detroit
Director of operations within the Provider Network Management Department. This includes departmental compliance with regulatory bodies; program management; network adequacy and expansion; the framework for relationship management; and implementation of departmental processes, policies and procedures for effective divisional activities. Provides leadership to staff on the operations team including project management.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Directs all activities to ensure that Provider Network Management remains compliant with NCQA, Medicare, HMO, and Exchange regulations. Partners with HAP SMEs to maintain up to date knowledge of regulatory requirements.
Oversees Provider Network Management adequacy and expansion area filings, including timeliness, accuracy, and CMS challenges or questions. Assures that HSD tables are accurate and reflective of Provider Network contracts.
Leads project management for Provider Network Management
Monitors and assures network adequacy for all HAP product lines
Responsible for new partner integration within Provider Network Management
Responsible for design and maintenance of current contract templates in collaboration with the Legal team.
Oversees design, implementation, and ongoing maintenance of PNM policies and procedures.
Develops a comprehensive understanding of the SEM physician and hospital universe and assures a full compliance verification of the networks. Develops and audits network analytics for provider network statistics so that HAP has reliance in Provider Network Operations for PCP/Specialist/Hospital official counts. Develops Geo Access software implementation for Department. Utilizes Strenuus as a tool to monitor departmental statistics.
Oversight of audit process for contract configuration including peer review process for charge changes submitted from hospital systems and review of Facets Modeler rates to ensure they are implemented into production.
Monitor the translation of contract terms into configuration requests and the overall configuration process for provider contracts, acting as a liaison between the Provider Contracting and the Business Configuration Team (BCT).
Collaborates with multi-departmental team to ensure the provider directory meets compliance standards.
Automate the entire provider contracting process and implement a Contract Lifecycle Management system.
Leads efforts to respond to RFPs on behalf of Provider Network Department.
Oversight of corrective action plans as needed related to network adequacy and compliance
Design and oversight of the relationship management framework (key partner collaboration teams)
Perform other related duties as assigned.
Master’s degree in business, healthcare
Minimum of five (5) years’ experience in the health care field. Experience working with provider groups and health systems preferred.
Proven Management of complex projects including staff and assurance of expected outcomes
Strong contextual knowledge (managed care, provider reimbursement models, national health care trends, practice management trends, risk modeling)
Health Alliance Plan (HAP) is a nonprofit, regional health plan headquartered in Detroit.
Our mission: “to enhance the health and well-being of the lives we touch.”
HAP excels in delivering award-winning disease management, wellness and community outreach programs, and highly personalized customer service.
Henry Ford Health System Alignment:
• HAP is a subsidiary of Henry Ford Health Sys...tem, one of the national’s leading health care systems and a proud recipient of the 2011 Malcolm Baldrige National Quality Award for performance excellence and innovation.
• HAP serves an important role in promoting system integration and care coordination and acts as a catalyst in forming innovative patient care, community, business and economic partnerships. As the voice of the customer, HAP partners with HFHS to improve quality while maintaining a focus on value, affordability and accessibility.
• HAP has more than 1,300 employees in Detroit, Southfield, Flint and Grand Rapids.
• We serve more than 650,000 members through six product lines:
o Group Insured Commercial: PPO, EPO and HMO; Health Engagement programs offer employees incentives to adopt a healthier lifestyle.
o Individual: HAP Personal Alliance PPO, HSA and Short-Term health plans are for individuals and families not covered through employer health insurance.
o Medicare Solutions: HAP Medicare Solutions offer PPO and HMO plans, prescription drug plans, and Medicare Supplement plans for individuals and employer-sponsored retirees.
o Medicaid: HAP Midwest Health Plan has about 10,000 Medicare and Medicaid enrollees.
o Self-Funded: HAP and ASR Health Benefits offer competitive options for Michigan companies and health and welfare funds seeking to self-fund their health benefit costs.
o Network Leasing: Statewide PPO network that can be administered by Third Party Administrators and Welfare Funds