The Director of Network Contracting and Operations develop and maintains a national Behavioral Health provider network yielding a geographically competitive, broad access, stable network that achieves objectives for unit cost performance and trend management, and produces an affordable and predictable product for customers and business partners. Development, implementation, oversight and management of APS’ networks, network operations, and BH and EAP credentialing program.
1. Oversees APS credentialing process and vendor credentialing functions to ensure adherence to APS credentialing policy and procedures, NCQA standards, state regulatory requirements, and/or client specific requirements.
2. Directs vendor activities regarding recruitment and maintenance of network, including accurate and timely demographic updates and network reporting. Handles interactions with clients regarding network needs and access. Manages vendor responsible for credentialing and network maintenance.
3. Oversees network maintenance functions performed by APS staff.
4. Maintains a network that meets the business needs of APS and all client and regulatory requirements, including contracting, rates and cost of care and ongoing quality, size and availability of the networks.
5. Oversees provider searches and single case agreement process performed by vendor or APS staff.
6. Manages all provider communication and education including provider manuals, newsletters, web information, trainings and other types of communication.
7. Responsible for credentialing of APS Medical Directors and Physician Advisors
8. Manages the resolution of key provider/facility issues and concerns.
9. Develops fee schedules and reimbursement methodologies, with a responsibility to contribute positively to APS cost of care results, in coordination with Finance and Clinical Operations.
• Bachelor’s Degree in business, management or related field
• A minimum of 8-10 years current related experience is required
• Minimum 8-10 years provider network and credentialing experience with commercial, Medicare and Medicaid lines of business.
• Minimum 5 years management experience or project management experience
• Knowledge of NCQA standards of credentialing and credentialing best practices, primary source verification, CVO operations
• Knowledge of contracting, rate negotiations, fee schedules, behavioral health, network management, facility operations and provider relations
• Knowledge of geo access reporting and network access best practices and trends
• Ability to manage projects and supervise staff
• Ability to work with large network development for new business
• Excellent written and verbal communication skills
• Excellent presentation skills for client and prospect presentations
• Strong customer service skills
• Strong MS office skills including excel, word and PowerPoint
• Strong negotiation skills
• Demonstrated ability to manage an operation with multiple complex components in a fast paced environment
• Exceptional analytical skills including data analysis
APS Healthcare - 15 months ago