Job Description

Job Title: Director, Network Management & Development - FQHC Strategy
Job ID: 754511
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Natl Network Mgmt
Location: 600 Grant St, Pittsburgh PA 15219

Description

Under the general direction of VP National Network Development and Strategic Expansion, the Director of Network Management and Development, FQHC Strategy, provides operational oversight to all aspects of provider relationship management and performance of contracted FQHCs,  and directs the FQHC network development, contracting  as part of UPMC Health Plan’s product and geographic expansion efforts. The Director will make recommendations regarding provider initiatives to support UPMC Health Plan goals and objectives related to FQHC’s.  The Director will be responsible for the strategies to improve provider performance and satisfaction as well as for the overall FQHC contracting strategy and goals to ensure the network is appropriately maintained and meets geographical and specialty coverage. The Director will provide support  to the VP National Network Development and Strategic Expansion , as well as supervision to  Network Management and Development employees.


Responsibilities:

  • Acts in an advisory capacity to legal with regard to the financial and legal impact of provider contract language requested. Works directly with legal representation to insure agreements are acceptable and compliant with other affected internal departments, including utilization management, credentialing, and reimbursement.
  • Directs a variety of personnel actions including employment, termination, personnel development, performance reviews, salary reviews and disciplinary actions.
  • Directs all aspects of Network Management & Development operations, including but not limited to, resolution of contract disputes, claims inquiries, implementation of provider performance initiatives, analysis and submission of GeoAccess reports to regulatory agencies (e.g. Department of Health (DOH), Department of Public Welfare (DPW), policy creation and compliance.
  • Directs maintenance of all departmental policies and procedures. Insures that policies and procedures are current, incorporate new product implementation, and will satisfy regulatory requirement when applicable.
  • Directs the department involvement with Health Plan quality initiatives such as HEDIS, CAPHS, and NCQA.
  • Directs the development of provider communication and education regarding departmental and UPMC Health Plan's overall goals and objectives. Insures that all internal departments are appropriately involved with network development and expansion. Works in conjunction with these departments concerning rate negotiations, rate configuration, provider services education, and marketing.
  • Directs the establishment and maintenance of strong business relationships with Hospitals and physician providers.
  • Directs the negotiation of complex contracts with physician, ancillary, PHO/PPO groups and hospital providers. Incorporates alternative solutions in order to resolve contractual obstacles and insure the ability to operationalize all points contained.
  • Directs the review, responses, and facilitates Requests for Proposals (RFPs) from product areas or external entities.
  • Oversees the recruitment and contracting of physicians and hospitals within the current service area and all expansion areas and ensures network composition includes an appropriate distribution of provider specialties. Works directly with Credentialing Department to insure appropriate processing is completed for all network participants.
  • Provides support to the Assoc. VP of Reimbursement and Network, and ensures the timely delivery of requested network data and analysis, as well as for the requests from other internal departments. Insures that network data is current and accurate while incorporating this data for purposes of continued network expansion.

Qualifications

  • Bachelors degree in Business, Health Care or Financial studies, or related field with minimum of 7-10 years of experience in managed care setting. 
  • Three years of management experience in managed care plans (experience in Pennsylvania programs strongly preferred). 
  • Excellent verbal and written communication skills, analytical and organizational skills are required. 
  • Extensive problem solving experience is required. Ability to multi-task, shifting back and forth effectively between two or more activities or sources of information. 
  • Experience implementing product expansion efforts preferred.


Licensure, Certifications, and Clearances: N/A


UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $0 / hour

Union Position: No

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