Develops the overall Provider Network contracting strategy for all CHOICE Networks and associated Provider Relations Department, which includes contracting, orientation and servicing of all Physician, Ancillary, Nursing Homes, LHCSAs, and Hospital Providers rendering care to CHOICE Health Plans. Oversees the development of incentives, processes, policies and procedures for network development and performance to ensure alignment and support of the company’s various product offerings. Works collaboratively with operations to resolve provider issues. Ensures compliance with all state and federal regulations, as well as VNSNY CHOICE policies and procedures. Works under general direction.
- Collaborates with CHOICE leadership to identify network and provider management opportunities that support achievement of member growth and increased quality and efficiency, including Value Based Payment contracting. Identifies and recommends best practices for operational improvements and performance for CHOICE Health Plans.
- Collaborates with CHOICE Health Plan leadership to review network and provider performance and identify unmet service needs to ensure overall satisfaction, especially with the CHOICE IPAs and key providers that align with growth strategies; recommends new/corrective actions as appropriate.
- Leads the development and negotiation of contractual relationships with external vendors and providers that render care to CHOICE Health Plans. Participates in the oversight of relationships, ensuring performance metrics are achieved and identifying and implementing opportunities for improvement.
- Leads the development and implementation of strategies to meet network capacity and regulatory requirements. Works with other VNSNY departments and business units to coordinate their roles or requirements in provider contracting, network performance, reimbursement and other related matters.
- Assesses network requirements as defined by VNSNY CHOICE leadership for enhancements or future product offerings. Monitors and analyzes network needs through review of provider utilization, member demands, program staff’s requests, provider performance, market trends and other information. Implements changes and improvements, as appropriate.
- Directs all provider recruitment activity. Works with Product teams to identify providers and develop provider recruitment and orientation strategies based on network requirements of each product line. Oversees the recruitment process to identify and establish relationships with various service providers.
- Identifies common issues affecting provider networks; works with Account Management staff and health plan colleagues in developing solutions.
- Ensures compliance with all regulatory reporting requirements to SDOH and CMS, including but not limited to Health Provider Network (HPN), Health Services Delivery (HSD), Medicare Part C reporting, and provider directories.
- Maintains visibility in the provider community by attending provider-sponsored events, seminars and conferences.
- Works with Quality and Clinical Management Department to ensure quality assurance monitoring of network providers.
- Keeps abreast of current industry trends, governing regulations, reimbursement practices and market players. Keeps VNSNY CHOICE management informed of trends/changes and makes recommendations based on this information.
- Performs all duties inherent in a senior managerial role. Approves staff training, hiring, promotions, terminations, and salary actions. Prepares and ensures adherence to department budget.
- Participates in special projects and performs other related duties as assigned.
Education:Bachelor’s Degree in Business, Health Administration, Health Policy, a related discipline or the equivalent work experience required.Master’s degree in Business, Health Administration, Health Policy or related discipline required.
Experience: Minimum ten years of experience in health care, with a minimum five years in a managed care environment and five years in health care management required. Experience negotiating hospital, IPA, Nursing Homes, LHCSAs and provider contracts required. Experience negotiating risk and Value Based Payment contracts required.
The Visiting Nurse Service of New York (VNSNY) is one of the nation's largest not-for-profit home- and community-based health care organizations, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Counties. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost-effective health care in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, health plan members, and clients from before birth to the end of life. On any given day, VNSNY employees - including nurses, rehabilitation therapists, social workers, home health aides and other professionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to approximately 40,000 individuals in our care helping them to live the best lives possible in their homes and communities.