Director Network Performance & Engagement

Amerihealth Caritas•Southfield, MI

1d•Hybrid

About The Position

The Director, Provider Network Performance & Engagement is responsible for leading strategies and initiatives to optimize provider network performance, advance value-based contracting, and strengthen provider relationships.

Requirements

Bachelor’s degree required.
5 or more years of provider contracting experience with various reimbursement models.
10 or more years of healthcare strategy, provider relations, or network management.
Strong knowledge of provider network management, provider contracting, and reimbursement methodologies.
Demonstrated experience developing and executing provider network strategies that support quality, cost, access, and performance goals.
Ability to lead value-based payment strategies, risk-sharing arrangements, and complex provider negotiations.
Strong analytical skills with the ability to interpret utilization, financial, quality, and network performance data.
Knowledge of network adequacy standards, access requirements, and state and federal managed care regulations.
Ability to identify cost drivers, performance gaps, and provider access issues and develop targeted improvement strategies.
Strong understanding of HEDIS, CAHPS, NCQA, and URAC quality standards.
Excellent leadership and people management skills, including staff supervision, performance management, and departmental planning.
Strong relationship-building skills with providers, executive leadership, internal departments, and external stakeholders.
Excellent written and verbal communication skills, including the ability to present complex information to executive audiences.
Ability to collaborate cross-functionally with quality, analytics, finance, operations, and compliance teams.
Strong problem-solving, decision-making, and strategic planning skills in a fast-paced managed care environment.

Nice To Haves

Managed care experience preferred

Responsibilities

Lead initiatives to monitor and improve provider performance, focusing on quality, efficiency, cost of care, and patient outcomes.
Responsible for development and execution of annual provider network strategy to include network adequacy standards, value-based strategies to drive and improve outcomes and engagement, and strategies to deliver a market-competitive network.
Analyze utilization and financial performance data to identify cost drivers and implement targeted interventions.
Oversight of VBP negotiations, VBP Contract performance, and leading VBP strategies in collaboration with internal stakeholders.
Monitor SCA and out-of-network utilization and trends, and develop contracting strategies to improve and increase in-network utilization.
Responsible for departmental staffing decisions and provides supervision to assigned staff, writing and performing annual reviews, and monitors performance issues as they arise.
Ensures department staff remain compliant in all aspects of Federal and State rules, regulations, policies, and procedures, and creates or modifies departmental policies to reflect changes.
Establish key performance indicators (KPIs) and regularly report on network performance to executive leadership.
Actively partners with the Market Director of Quality to drive Company-wide and Plan quality initiatives, such as Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and National Committee for Quality Assurance/Utilization Review Accreditation Commission (NCQA/URAC), and analytics teams to ensure alignment on performance strategies.
Responsible for oversight of network adequacy monitoring and managing provider network, developing strategies to close gaps, and ensuring appropriate access to services throughout the Plan’s territory.
Oversight of large-scale provider terminations to include tracking, reporting, and identifying risks and strategies for gap closure and access.
Ensures provider contracts are consistent with organizational guidelines, claim payment methodologies, and state and federal regulatory requirements.
Ensures that non-standard contract elements are tracked and communicated to appropriate departments and obtains AHC and Plan approval before submission to the provider.
Responsible for leading complex negotiations for facilities and value-based contracts for clinically integrated networks.
Other duties as assigned.