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Senior Director Provider Contracting

Company: MetroPlus Health Plan
Location: New Haven
Posted on: January 9, 2021

Job Description:

About NYC Health + HospitalsMetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus' network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.--Position OverviewTo provide the administrative and management support necessary to achieve the goals and objectives of MetroPlus, specifically as they relate to ensuring a comprehensive cost efficient and accessible provider network that is credentialed, contracted, and linked to appropriate fee schedules. Also, to serve as the organization's liaison, on contracting matters with all departments involved in contracting processes.Job Description

  • Negotiate contracts and manage relationships with participating Hospitals, IPAs, Ambulatory Surgery Centers, Urgent Care facilities, and Physician Groups;
  • Help develop both the short- and long-term network and contracting strategies for the Plan;
  • Manage the Contracting Director and the end-to-end contracting process, including outreach, recruitment, contract initiation, amendment mailings, and provider terminations.
  • Manage the Credentialing Director and department; ensure all credentialing functions are operating timely and according to policy and regulatory requirements;
  • Manage the Provider Maintenance Manager, and the Provider Maintenance Department to ensure all provider fee schedules, both in- and out-of-network, are linked and loaded appropriately.
  • Negotiate and review all existing and proposed hospital and large provider contracts. Ensure that reimbursement is competitive, and appropriate for the facility, for the product line, and identify cost saving opportunities for MetroPlus;
  • Manage both the Physical and Behavioral Health provider network; ensure adequacy; ensure payment is competitive and meets regulatory guidance.
  • --Coordinate MetroPlus' network development and contracting strategy as MetroPlus expands into new lines of business;
  • Work with Legal to review and modify any negotiated provider contract language changes as necessary and appropriate;
  • Manage an Out-of-Network strategy that addressed high cost out-of-network cases for all lines of business, but primarily for the Commercial and Exchange products;
  • Supervise a team of Directors and Managers (Contracting, Credentialing, and Provider Maintenance), and manage the budget for the entire department;
  • Providing support necessary for the development of policies and strategic direction for expansion of a comprehensive network;
  • Work with Analytics Department on rate development and related activities, specifically as they relate to the evaluation and analyses of reimbursement structures consistent with industry norms and trends and cost containment initiatives
  • Work with Analytics Department to address all contract-monitoring activities, specifically as they relate to providers' compliance with contract terms and conditions;
  • Collaborating with MetroPlus departments in the development and evaluation of proposals for operational improvements and new products, and make recommendations as they relate to improved performance and cost effectiveness;
  • Assist Network Relations Department in directing and maintaining relationships with providers through education and provider relations efforts, including assistance in Marketing initiatives to promote membership growth;
  • Perform other related functions as required.Minimum Qualifications
    • Bachelor's Degree in Health or Business Administration required. Master's Degree in Business, Health Care Administration, or related field.
    • Minimum of 7-10 years senior operations management experiences, including a minimum of 3 years managed care experiences.
    • Proven ability to achieve organization's missions, goals and objectives or an equivalent combination of education and experience.Licensure and/or Certification Required:
      • Attorney licensed in New York, preferred.Professional Competencies
        • Integrity and Trust
        • Customer Focus
        • Functional/Technical Skills
        • Written/Oral Communication

Keywords: MetroPlus Health Plan, New Haven , Senior Director Provider Contracting, Executive , New Haven, Connecticut

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