The Senior Director provides leadership and direction for the successful operations and effective network development that integrate the goals of MemorialCare Medical Foundations (MCMF) Strategic initiatives and other activities for the areas of Network Development, Provider Contracting and Provider Relations for all MCMF entities – including GNP and EMG, MCMF Contracted Specialists; Provider Relations only MCMG Providers; UC Irvine Health IPA; UC Irvine Health MSO when requested; in addition to any new entities brought into MCMF
This position is responsible for overall Provider Contract Administration including maintaining a Contract Management System to effectively manage contracts including new provider contracts, renewal processing and renegotiations, and any ACO Contract Maintenance in support of an ACO department. This position is accountable for monitoring network adequacy, alignment of necessary specialties and ensuring access to necessary medical specialties including tertiary services. The position is accountable for Provider Relations which includes a team of provider representatives, directory maintenance, event management, communication plans including department goals that include but are not limited to excellent service to our providers and clients, through the use of portals, education seminars, provider office visits, and various means of provider communications. Additional accountabilities include monitoring and oversight of the provider data integrity, and employee engagement. This position focuses on process improvement and strategies to increase effectiveness including LEAN initiatives, utilizing technology, people and standard work.
Principal Duties and Responsibilities:
Responsible for the strategic planning and management of MCMF’s contract negotiations, documentation and relationship management including ensuring network physician/providers are adequately trained and satisfied with working with applicable entities. Advises and provides guidance to other emerging Memorial markets on contracting standards, which may include contract template review and input to senior management on recommended strategies, as well as involvement in specific negotiations and documentation.
Collaborates with other departments to develop assessment and communication tools to monitor performance of the agreements and other information critical to the organization and oversee the review, negotiation, implementation and maintenance of capitation and fee for service contracts and related materials consistent with organization’s strategic goals, business and marketing plans.
Oversees the proper set-up and inclusion of the various products within each Health Plan and the maintenance of Health Plan websites/rosters to ensure timely and accurate information of MCMF providers.
Responsible for leading the department teams to increase effectiveness and implement strategies for department in order to improve relations with outside network providers and internal departments.
Directs the contracting and provider relations staff. Oversees the day-to-day productivity of the department and provide leadership and guidance to Managers with interviewing, hiring, evaluations, training, staff development, employee engagement and resolution of issues.
Responsible for preparing and adherence to department budgets.
Oversees or provides direction of all Managed Care portal related business functionality including understanding and providing guidance with workflow issues particularly in the area of referrals. Ensures that staff are working with IS Department to improve Managed Care provider portal functionality and overall content.
Oversees or provides direction on analysis of performance of provider contracts and collaborates with executive management on opportunities for lowering the cost of providing medical services using contractual relationships.
Keeps informed on new provider compensation strategies or methodologies such as capitation, bundled payments, and pay for performance opportunities or other means of compensation incentives to engage providers with MemorialCare strategies.
Collaborate with management and staff from other departments to develop standard processes, resolve issues and further the business goals of the company.
Collaborates with IT on contract maintenance issues ensuring fee schedules are updated in conformance with contract requirements including consulting with MemorialCare IT Epic Tapestry subject matter experts on implementation of new contractual terms.
Advise senior management on provider network strategies (develops, executes and maintains) to meet the needs and goals of physician groups and Hospitals.
Oversee the negotiation and renegotiation of provider contracts and letters of agreement.
Ensure data integrity in the EPIC managed care system in regards to provider pricing and provider demographics.
Oversee provider inquires as it relates to contract/claims issues and works with providers and office staff to ensure claims are paid according to contractual terms.
Works in concert with medical management and marketing to develop strategies to meet market growth and medical cost targets.
Perform any additional/miscellaneous duties (not inclusive of job description) as requested by management team and within scope of knowledge/ability.