The Director of Managed Care and Network Operations coordinates the activities and communications among managed care staff and the administration. The Director of Managed Care and Network Operations works collaboratively with Administration, Finance, Clinical Programs, Operations, Credentialing, Pharmacy, Data Analytics and others to research, develop, plan and implement innovative managed care strategies that maximize success in managed care. The Director of Managed Care will be responsible for negotiating managed care contracts and ensuring that requirements and initiatives are successfully executed within the healthcare delivery setting resulting in improved access to contracted services, improved outcomes, superior care and increased profitability.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

The Director of Managed Care and Network Operations is responsible for the following:

• Plan and direct the managed care program.
• Oversees the managed care plan operations, obligations & responsibilities inter-departmentally through the Clinicas System.
• Directs the department operations, activities, resources to meet budget and goals.
• Communicates and resolves issues.
• Initiate and lead the process of development, negotiation, implementation, monitoring and management of all managed care agreements.
• Conducts complex language and financial analysis with contracted providers and/or entities. Implements legal, financial & business requirements & objectives through negotiations.
• Develop, deploy and oversee contract strategy for hospitals, ancillaries, physicians and other professional services. Ensure services are in compliance with professional standards, local, state and federal regulatory requirements.
• Monitor health plans, providers, businesses and agencies to ensure that they efficiently and affectively provide needed services while staying with contractual agreements.
• Assist in developments of policies and procedures to adhere to the contractual agreements.
• Oversees the managed care plan, operations, obligations & responsibilities inter-departmentally throughout the Clinicas System. Directs department operations, activities, resources to meet budget and goals. Communicates and resolves issue.
• Develop and oversee the implementation of strategies to improve managed care performance in terms of utilization, patient access, cost, compliance with contractual quality measures, etc. Align improvement with quality and financial goals.
• Lead the identification, coordination and analysis of all financial, access and utilization data that results in clear business performance reporting and monitoring by payer and by lines of business. Works closely with Operations, Clinical Programs, Credentialing, Finance/Managed Care Analytics to do so.
• Review financial statements, contract and fee reports, and other performance data to measure trends and goal achievement, determine areas needing cost reduction and program improvement.
• Partner with leadership from Clinical Programs, Operations and Quality to develop and implement change strategies in the healthcare delivery setting.
• Plans and monitors activities and staff including hiring, orienting, training, mentoring, continuing education, and evaluating, coaching & disciplinary actions of supervised staff members.
• Perform other duties as assigned including participation in all safety programs which may include assignment to an emergency response team.