Manager, Network Management at Alignment Healthcare USA, LLC in Orange, California

Job Description:

POSITION SUMMARY:
The Manager, Network Management is responsible for contracting with all provider types and successful provider network performance related to key financial, operational, and member satisfaction performance indicators. Works closely with other departments to enhance the contracted provider experience consistent with company's mission statement and values.

GENERAL DUTIES/RESPONSIBILITIES (MAY INCLUDE BUT ARE NOT LIMITED TO):
• Responsible for the overall performance of the network within a designated region and for assuring that the day-to-day operations of the provider network are consistent with standards/ expectations, and develops provider education materials as needed to support adherence with company requirements.
• Negotiate / re-negotiate and finalize all assigned contracts which may be primary care, specialist, ancillary, hospital, group/IPA as well as ensure the accuracy of administration of these agreements.
• Develop agendas and lead regularly scheduled Joint Operations Meetings to drive results, including oversight of New Provider Orientations and new Contract Orientations. Ongoing meetings will focus on addressing performance improvement metrics, resolving operational issues, including but not limited to utilization management, financial, enrollment, member appeals and grievances, provider termination/panel closures, continuity of care, and marketing activities.
• Responsible for the execution of regional work-plans, monitoring performance metrics, updating status, and communicating progress both internally and externally to ensure results.
• Responsible for overseeing physician adds and successful completion of physician credentialing, and NOC process for physicians adds.
• Acts as technical resource on provider relations issues and offers strong, collaborative leadership internally as well as externally. Responsible for timely and professional interaction with internal and external customers.
• Interpret company policies and procedures.
• Ensure accurate and timely data reporting requirements are being met for designated regions, including but not limited to provider network contacts, eligibility and capitation reports, risk sharing, claims timeliness, pharmacy utilization, bed day utilization, encounter data and audit compliance.
• Develop goals and objectives that align with Network Management Director's performance metrics to ensure department KPIs are met, as well as the organization's vision for future growth and network development.
• Utilize contracting knowledge for effective problem resolution and compliance. Responsible for timely and professional interaction in response to grievances. Research, analyze and resolve complex problems dealing with hospital shared risk pool, claims, appeals, and eligibility issues within the appropriate limits.
• Manage the activities and development of the Network Management Specialists and Contract Coordinators
• Represents the department in interdepartmental meetings and selected committees.
• Other duties as assigned.

SUPERVISORY RESPONSIBILITIES:
Oversees assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.

MINIMUM REQUIREMENTS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Minimum Experience:
a. Minimum 5-7 years' experience with an HMO, managed care provider organization (IPA, Medical Group or institutional provider) or insurance company with at least 3 years' specific experience in managed care contracting and knowledge or Medicare Advantage regulatory guidelines.
b. Proficient in MS Office, including strong Word and Excel proficiency.
2. Education/Licensure:
a. Bachelor's Degree or equivalent experience required
3. Other:
a. Detail oriented.
b. Language Skills: Ability to read and interpret documents such as contracts, safety rules, operating and maintenance instructions and procedure manuals. Ability to interpret government regulations a must. Ability to write routine reports and correspondence.
c. Ability to speak effectively before groups of providers or employees of internal/external organization.
d. Mathematical Skills: Ability to calculate figures and amounts such as fee schedules, per diem rates, discounts, interest, commissions, proportions, and percentages. Ability to apply concepts of algebra, geometry and statistics.
e. Reasoning Skills: Strong analytic and problem-solving skills required, including ability to synthesize, interpret and apply detailed and complex information.
f. Office Hours: Monday-Friday, 8am to 5pm. Extended work hours, as needed.
g. Maintain reliable means of transportation. If driving, must have a valid driver's license and automobile insurance.
h. Drives approximately 20-40% of the time to provider sites.
4. Work Environment:
a. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

ESSENTIAL PHYSICAL FUNCTIONS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.