Under the direction of the Vice President of Health Care Network Operations, and in accordance with the objectives and policies of the Health Plan: (a) provides strategic direction, planning, and oversight of end to end processes and related technologies related to provider set up and rate implementations (b) oversees strategic resource management and quality control/improvement efforts (process, processor, service requests, projects) (c) implements, drives and provides oversight of new and improved processes and strategies for effective execution of priority initiatives (service requests, projects, escalations, strategic initiatives).
End to End Process
• Responsible for the strategic planning and deployment of activities associated with the critical end to end business processes which tie provider satisfaction.
• Defines, reviews and leads discussions with management throughout the organization regarding new provider/facility implementations, provider/network/facility maintenance and other critical issues related to process.
• Accountable for identifying gaps in our processes and implementing and driving changes to fix those gaps. Works closely with management of all impacted areas to achieve these changes.
• Oversees innovative projects for process redesign and business efficiency. Drives process changes throughout the Health Care Network Management and Provider Contracting areas.
• Implements and oversees end to end monitoring of physician, ancillary, and rate implementations including identifying and addressing roadblocks, setting priorities, balancing resources, and communicating results to internal and external stakeholders.
• Partners with key stakeholders to develop reimbursement and reimbursement configuration strategy for physician, ancillary, and facilities.
Resource Management, Quality, and Control
• Oversees and facilitates implementation of root cause remediation of provider related escalations, including tracking, trending, facilitating teams, assessing solution options (operational, financial, external impact).
• Identifies and remediates quality and control issues in the areas of provider data, reimbursement, and network set up utilizing data analysis, profiling, and other methods.
• Works with teams within and outside of Health Care and Network Management to identify system issues, articulate business need, and executes (via SR, project, or process change).
• Provides and leverages system-based reporting for quality assessment, quality control, analysis, and decision making.
• Manages Provider Satisfaction Theme Committee; this includes assessing impact of issues, prioritizing issues, and ensuring efficient and effective resolutions of system related issues.
• Provides strategic oversight to resource management staff such as forecasters, analysts, and leads in forecasting inventory, productivity, work assignments, and quality plans.
• Supplies team level and executive level reporting on inventory, productivity, quality, key initiatives that is used for decision making around staffing levels, work assignments, prioritizing corporate initiatives, and management of priorities.
• Prepares reports and makes detailed presentations to staff, project teams, department heads and all levels of management regarding the business situation, status of new processes and initiatives in place for continuous improvement and change.
• In partnership with the Vice President of Health Care Network Management Operations oversees budget, budget phasing, and variances. Acts as point person for budget related decisions and temporary resource management.
• Ensures procedures are in place and being followed appropriately across all regions to eliminate corporate risk.
• Maintains an in-depth knowledge of all relevant BCBS Association regulations and ensures that all Health Care Network Management processes are in compliance with these requirements. Takes immediate and decisive action, when they are not.
• Serves on various task forces and committees as assigned to lend expertise and assures that Health Care Network Management Operations needs are satisfied.
• Develops comprehensive implementation work plans for process implementation issues, oversees associated tasks and presents results and decisions to internal staff and providers as needed.
• Directs project teams in the completion of the technical and business analysis required throughout the project. Provides knowledge and expertise of testing requirements and tools utilized to ensure completion of test plans and test scenarios robust enough to identify exceptions and/or implementation risks.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
• Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
• Bachelor’s Degree in Business Administration or similar discipline and a minimum of 10 years progressive experiences within an operational setting. In lieu of degree, a minimum of 12 years progressive experiences within an operational setting including a thorough knowledge of Health Plan Processes and Operations.
• A minimum of 4 years’ experience in Operations management is required.
• Strong Project Management skills and experience are required. PMI certification is a plus.
• Strong understanding; demonstrated experience and abilities in Process management.
• Creative problem solving skills.
• Strong matrix management skills. Able to lead project teams to high levels of achievement.
• Outstanding communication and presentation skills.
• Organizational skills, including the ability to manage personnel across multiple locations.
• Proactive thinker with a demonstrated ability to drive solutions to completion.
• Computer proficiency, including intermediate experience in Microsoft Office Suite
• Additional training in administrative management, supervisory techniques, project management concepts and experience in budget and planning processes preferred.
• Experience or knowledge in health care network reimbursement, provider set up, provider market dynamics preferred.
• Experience in metrics, data analysis, or trend analysis required.
• Mastery of business writing, technical writing, process improvement skills, project management expertise, and proven group facilitation and presentation skills,
• Ability to establish effective liaisons with other areas of the corporation.
• Leadership skills including ability to create and lead high performing teams
• Creative/proactive thinker who demonstrates initiative
• Ability to create meaningful simple visuals that convey complex ideas clearly and effectively
• Ability to work effectively when under deadlines
• Ability to interface effectively with all levels of management (with emphasis on SVP s, VPs, and directors) internally or externally.
• Use of a computer and phone, plus the ability to travel.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer