Provider Network Director Insurance Job

Our client is a leader in the Medicare Advantage market and is in the forefront of innovative Fee-For-Service and network-based products that minimize or eliminate many of the concerns hospitals have about providing service in the Medicare environment.  They are seeking a dynamic leader in the Southeast Region to direct all provider network development and management for the territory.  This individual will be accountable for the full range of provider contracting, relations and services interactions including negotiations, contract installations, working end-to-end provider claim and call quality, ease of physician portal and future services enhancements and training and development of external provider education programs.  

Provider Network Director Responsibilities

• Direct and implement strategies relating to the development and management of a provider network.

• Develop the provider network (national providers, multi-hospital systems, ancillary groups and facilities, integrated provider networks, etc.) yielding a geographically competitive, broad access, stable network that achieves objectives for unit cost performance and trend management, and produces an affordable and predictable product for customers and business partners in assigned region and specialties.

• Evaluate and successfully negotiate cost-effective contracts in compliance with company contract templates, reimbursement structure standards, and other key process controls.

• Identify and prioritize negotiation of all region contracts.

• Track renewal or expiration dates of contracts and any non-standard rates or terms.

• Identify gaps in network composition and services to remain compliant with regulations.

• Design and implement programs to build and nurture positive relationships between the health plan, providers (hospitals and facilities) and hospital administrators. 

Provider Network Director Requirements

• Bachelor's degree required with MBA or MHA degree strongly desired.

• 7-10 years of past contracting experience.

• Knowledge of provider contracting from both the payer and provider perspective.

• Experience with reimbursement methodologies for Medicare and commercial insurance, including common claim review logic and regulatory requirements concerning provider contracts.