Monday, October 14, 2013

Provider Network Director, Encino, CA


As a part of the Tenet and Catholic Health Initiatives family, Conifer Health Solutions is a leading healthcare business process management services provider working to improve operational performance for more than 600 clients so they can support financial improvement, enhance the patient experience, and drive value-based performance. Through our revenue cycle management, patient communication s, and value-based care solutions, we empower healthcare decision makershospitals, health systems, physicians, self-insured employers, and payersto better connect every point of care and wellness management. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Conifer Health Solutions is currently hiring for a Provider Network Director in Encino, CA.

Position Summary:

Responsible for strategic direction and the day-to-day operations of the Provider Networks. Manages and directs the development and implementation of an overall business and financial strategy for the Provider Networks. Manages all facets of Provider Network operations to carry out growth initiatives. Manages and directs staff and the clerical function of the Provider Network Department.

Degree of Supervision:

This position reports to the Chief Operating Officer and requires minimal degree of supervision to ensure tasks are appropriately prioritized.

Job Duties and Essential Functions:

  • Responsible for the overall financial performance of the Provider Networks. Conducts ongoing financial analysis and implements performance improvement plans as needed to ensure optimal financial performance.

  • Analyzes monthly IPA financial statements, claims and UM analysis, stop loss detail reports, HMO and provider contract performance and makes recommendations for improvement.

  • Interfaces with other internal departments to analyze, review, and, make recommendations for financial analysis of 1) provider contracts, 2) health plan contracts, 3) quality improvement initiatives, 4) care management issues, 5) marketing plans, and 6) capitation and claims payment issues 7) encounter data submission, and 8) eligibility issues.

  • Executes strategic planning and makes management recommendations to ensure operational and financial goals are met by the Provider Networks.

  • Ensures cost effective provider and ancillary contracts, limits use of non-contracted provider, controls use of non-capitated or non-preferred providers.

  • Oversees the development and implementation of marketing strategies to maximize growth in the IPAs

  • Directs the expansion and development of new IPAs

  • Ensures completeness of DOC required specialty panel to maintain compliance with payor requirements.

  • Coordinates and attends JOC meetings with DBDs, CEOs, and participates in network development and operational discussions.

  • Conducts IPA Board of Directors, UM, and QI meetings to review operational and financial position and develop improvement plans as needed

  • Resolves follow-up issues from IPA Board of Directors meetings and ensures that accurate and complete minutes are maintained and that action items are closed in a timely manner.

  • Responsible for the renewal of the annual IPA D&O/E&O insurance policy and Stop Loss insurance policy.

  • Facilitates and participates in IPA/Medical Group discussions, negotiations, corrective action plans and other administrative issues between IPAs, CMS, and health plans.

  • Ensures that annual calendars for PCP Forums and Office Manager presentations are in place.

  • Oversees and manages incidents in the Customer Service Module and other related IPA issues.

  • Develops and maintains written policies and procedures, criteria, documents information sources and develops matrices to provide periodic updates.

  • Oversees the development and implementation of educational initiatives for the training of providers, office staff and internal staff

  • Keeps abreast of Federal and State requirements by attending seminars and/or conducting in-services as appropriate

  • Assists in the interviewing, hiring and coaching of Provider Network Department staff

  • Maintains relationships with key decision makers and influential players.

  • Attends and participates in CMS internal committees.

  • Maintains and keep in total confidence, all files, documents and records that pertain to the operation of business of Cap Management systems.

  • All other job related duties as relates to job function or as delegated by the management team.


Educational Requirements:

Bachelor's Degree or equivalent experience required.

Master's Degree preferred.

Experience/Skills Requirements:

Minimum of three years in Managed Care or related field. Minimum of 1 year of supervisory experience. Knowledge of HMO Insurance (Commercial, Senior & Medi-Cal). NCQA Credentialing guidelines. Provider Contract negotiations. Fluent in MS Excel, Word, Power Point and Access software systems.

Physical Requirements:

Light physical effort (lift up to 10 lbs.). Mostly sedentary work. Regularly needs to be able to bend, stoop and reach to file.

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