Manager, Medicare Network
AvMed Health Plans - Fort Lauderdale, FL

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Manager, Medicare Network

Ft Lauderdale
Level O
Reports to: Gustavo Leon, Jr.

SCOPE OF POSITION:
This position is responsible for developing and maintaining networks of Primary Care and Specialty physicians assigned to a geographic region(s). These networks must demonstrate high quality standards of medical services, cost effectiveness, and growth opportunity, while maintaining high member satisfaction. This position will work in conjunction with the Physician Contracting & Services Department to ensure that there is an ongoing outreach and proactive approach to ensuring high levels of provider service satisfaction, attainment of unit cost targets, and service goals. This position will support the Director of Medicare Network Contracting in evaluating the composition, performance, and cost effectiveness of the providers for which this position is responsible for; and make timely and well though-out recommendations to enhance the competitiveness of AvMed’s South Florida Medicare network management agenda.

ESSENTIAL JOB FUNCTIONS:
•Develop and maintain cost effective networks as measured by comparison with AvMed’s internal unit cost targets, market based/competitor experience, and market success via increasing market share.
•Maintain high quality network of physicians as measured by member satisfaction and quality indicators such as HEDIS scores for preventive care.
•Maintain a comprehensive network from the standpoint of meeting the appropriate geo accessibility standards and marketing needs, while at the same time directing enough business to providers to assess their quality and effectiveness.
•Maintain a network of physicians that aggressively project a positive image for AvMed, resulting in good internal working relationships and high member satisfaction. This will be measured by member satisfaction surveys, complaint ratios, member retention rate, and internal evaluation of physician office relationships.
•Responsible for ensuring the timely delivery of provider performance data reports and gain share distribution payments, while at the same time providing guidance with regards to the accuracy of the same.
•Responsible for maintaining an in-depth knowledge level of the general physician network in the community – professional issues, availability, quality, Ethnicity, etc.
•Assure network meets all regulatory requirements, as required by all governing agencies..
•Responsible for ensuring the effective orientation of AvMed’s policies and procedures and/or other educational material for those physicians and/or physician staff that request it, or would otherwise benefit from such information.
•Responsible for the timely and effective performance of all field investigations and resolution (as appropriate) of customer service problems experienced by participating physicians and/or their office staff. In addition, is responsible for the implementation of proactive programs to enhance the relationship of participating physicians and their office staff with AvMed, thus preventing or minimizing customer service problems/complaints.
•Is responsible to assure that the Physician Service Representative carries out all tasks with physicians and their office staff as directed by other AvMed departments such as Credentialing, Medical Operations, and QI.
•Responsible for maintaining good relations with the physician network – to include performance recognition, education and training programs, organization support, etc.
•Focuses on achieving departmental and organizational objectives.
QUALIFICATIONS:
•Bachelor degree, preferably in Business or Health Services Administration and/or the experience equivalence of 5 years experience in Managed Care network development, contracting, negotiation, and provider relations.
•Minimum of 3-5 years of management/supervisory experience in health insurance and/or Managed Care.
•Experience working in direct contact with physicians and/or physician office staff or sales experience.
•Experience and knowledge of the South Florida Managed Care market, preferably with a concentration in Medicare risk and gain share contract negotiation.
CRITICAL SKILLS/EXPERTISE:
•Strong management, planning, organization and communications skills (verbal and written)
•Negotiating and conflict management skills
•Risk and gain share provider contracting
•Experience in interpreting of performance based contract data.
•Ability to generate reports based on the analysis of comprehensive provider data
•Ability to develop and maintain strong Physician relations
•Knowledge and use of company systems (Amisys & Macess)
•Computer software for analysis, preferably Microsoft Excel and Word
•Skilled in the training/development of staff
•Knowledge of AvMed’s Quality Improvement/Quality Assurance/TQI standards.
WORKING CONDITIONS:
•Fast paced work environment
•Working on multiple priorities simultaneously
•Frequent travel and consistent presence in all parts of assigned region may be required, including overnight trips
•Occasional state-wide travel
AvMed Health Plans is a Drug/Tobacco Free Workplace EOE

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