Director of Provider Network
Apply on line at http://www.alohacare.org/Careers/Default.aspx
AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.
AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.
AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.
These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.
The role of the Director of Provider Network is to develop AlohaCare’s provider network as well as maintain effective provider services and contract data management operations. Collaboration with other operational leaders in claims, finance, information systems, credentialing and compliance is essential to success of this department. The Director must also build, lead, and mentor the Network team to create a strong infrastructure and control processes. S/he must also deploy best practices to grow and manage the external relationships required to assure access to high quality providers and healthcare services for all members. This leader has oversight to and is personally involved in pricing strategies, contract negotiations, contract data management, provider relations and access to care monitoring. The Director is mindful and committed to the AlohaCare mission and the provider partnerships needed to accomplish organizational goals. He/She reports to the Chief Operating Officer.
Primary Duties & Responsibilities:
• Responsible for strategic direction and day to day management of the following functions:
o Provider relations – responsible for the development and maintenance of a robust provider network that meets member and organizational needs by fostering provider collaboration and partnership;
o Network development – responsible for timely, accurate and consistent engagement of providers in contractual relationships with AlohaCare;
o Contract data management – end to end oversight of provider data and related reporting; and
o Branch office management – responsible for oversight of Neighbor Island branch office operations, including provider relations, office operations budget/expenses, landlord/vendor relationships, and local implementation of organization-wide employee activities.
• Develop and maintain a high quality provider network in a cost-effective manner that addresses the service needs of members throughout the State promoting access to medical, behavioral and LTSS benefits.
• Negotiate contract terms and collaborate with CFO and data analytics team on analysis of Medicare/Medicaid fee schedules, pay for performance models and prospective payment.
• Ensure effective troubleshooting of incoming issues from provider billing offices that must be assessed for root cause and addressed collaboratively with claims and IT staff.
• Train, manage, mentor, develop and provide guidance to department staff to improve individual skill sets and develop subject matter experts to enhance job satisfaction, promote employee development and retention, and to ensure employee performance meets or exceeds expectations.
• Accountable for meeting key performance indicators for timely and efficient processes and workflows.
• Ensure administration of the AlohaCare Medicaid QUEST Integration and Medicare Advantage Plus Special Needs Plan programs are compliant with Federal and State laws, accreditation standards, and other AlohaCare contractual obligations.
• Develops and maintains external relationships with MedQUEST, CMS Medicare, and other major stakeholders, local and national, as well as with ACAP (Association of Community Affiliated Plans).
• Demonstrates leadership attributes such as active listening, defining issues, resolving conflict, being facilitative, inspiring staff, empowering staff, and training the trainers.
• Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.
• Manages managers/supervisors who supervise Provider Network Department employees in the field and offices throughout the State of Hawaii.
• Partners with direct reports to train, manage, mentor, develop and provide guidance to department staff to improve individual skill sets and develop subject matter experts to enhance job satisfaction, promote employee development/retention, and to ensure employee performance meets or exceeds expectations
• Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws
• Responsibilities includes interviewing, hiring and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
• Bachelor’s degree in Health, business or other related field – Master’s preferred
• Five to seven years’ management experience in network development, provider relations and/or contracting in a managed care organization and/or provider organization with formal delegation for these functions is required
• Minimum five years Medicare/Medicaid operations experience
• Minimum three years of experience in management and supervision
• Valid driver’s license and access to vehicle to attend off-site meetings
• Managing and overseeing network operations including Managers, Supervisors and Staff
• Demonstrated track record of participation in audits and compliance programs
• Sound understanding of managed care processes and tools for provider services, contracting and credentialing
• Expertise with provider fee schedules, pricing models and contract negotiation
• Ability to synthesize data and information to develop recommended strategies
• Capable of developing effective working relationships with staff at all levels in the organization, and with network providers, committee members, and members of the AlohaCare Board of Directors
• Able to communicate effectively both verbally and in writing, including presentation skills
• Experience in P4P, value based purchasing and provider organizational development
• Master’s Degree – Health, business or related field
• FQHC expertise
Mental, Physical and Environmental Demands:
• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.
• Inside working conditions
• No environmental hazards
• Requires operation of general office equipment to include PC
AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.Position Description »