The document outlines the responsibilities of a Provider Network Management and Operations role. Key responsibilities include planning, organizing, and coordinating all activities of the department, developing and implementing provider contracting strategies, and overseeing the maintenance of provider contracts and contract templates. The role also contributes to senior leadership teams and committees addressing strategic goals.

1. *Plan,organize,staffs,andcoordinate all activitiesof the State Plan'sProviderNetworkManagement
and OperationsDepartment.Workwithstaff andSeniorManagementtodevelopandimplement
providercontractingstrategiesandprovidernetworkstrategies tocontainunitcost,improve member
access andenhance Providersatisfactionwiththe Plan.PrimaryplanliaisonforClaims,Provider
RelationsandotherCorporate Departments.
* Developandimplementsprovidernetworkandcontractstrategies,identifying those specialtiesand
geographiclocationsonwhichtoconcentrate resourcesforpurposesof establishingasufficientnetwork
of ParticipatingProviderstoserve the healthcare needsof the Plan'smembership.
* Developandmaintainamarket-specificProviderReimbursementStrategyconsistentwith
ReimbursementTolerance Parameters(acrossmultiplespecialties/geographies).Oversee the
developmentof newreimbursementmodels.ObtaininputfromCorporate andLegal regardingnew
reimbursementmodels.
* Directthe preparationandnegotiationsof providercontractsandoversee negotiationof contractsin
concert withestablishedcompanytemplatesandguidelineswithphysicians,hospitals,andotherhealth
care providers.
* Contribute asa keymemberof the SeniorLeadershipTeamandothercommitteesaddressingthe
strategicgoalsof the departmentandorganization.
* Oversee the maintenance of all Providercontractinformation,ProviderContractTemplatesand
assuresthat all contracts negotiatedcanbe configuredinsystem.
*Work withlegal andCorporate on an as neededbasistomodifycontracttemplatestoensure
compliance withall contractual and/orregulatoryrequirements.
* Oversee Plan-specificfee schedule management.
* AuditTPA relatedtoNetwork,ProviderRelations,Claims.
* Provide oversightof ProviderServicesandcoordinatesactivitieswithProviderAssociation(s) andJoint
OperatingCommitteeManagement.

2. * Provide accountabilityforDelegationOversightfunctioninthe Plan.
* Provide oversight of the ProviderNetworkAdministrationareaincluding:ProviderInformation
Management(PIM) andbusinessanalysesof contractsand benefitstosupportaccurate configuration
for claimspayment.
* Oversee all Providerproblemprevention,researchandresolutionandprovide oversightof the
ProviderAppealsandGrievance process.
* Coordinate withenrollmentgrowthtoensure thathealthplangrowsfaster(profitable growth) than
our competitorsinkeyproviderpractices.
* Complywithrequiredworkplace safetystandards.
* Adhere tothe companyand/ordepartmental confidentialitystandardsandHIPAA compliance
programs.
* Adhere tothe companyand/ordepartmental fraudandabuse prevention/detectionpoliciesand
programs.
*interpretationandresearchskillsin ordertoreadilyidentifyproblems,gettothe rootcause and
achieve promptresolutiontoproblemsandissuesincludinganalytical skills- ProficiencyinWord,Excel
and Outlook
* Abilitytoorganize,coordinate,andaccomplishahighvolume of workwithminimumimpacton
quality.
* Exceptional interpersonalrelationsskills
* Superiorverbal andwrittencommunicationskills
* Abilitytomaintainattendance tosupportrequiredqualityandquantityof work
* MaintainconfidentialityandcomplywithHealth InsurancePortabilityandAccountabilityAct(HIPAA)
* Abilitytoestablishandmaintainpositive andeffective workrelationshipswithcoworkers,clients,
members,providersandcustomers,HHSCandotherstate offices.
* Managedand reviewall State DeliverablesrelatedtoProviderNetwork,ProviderRelations -
Complaints,HUBS,Claims.