Provider network development lead for corporate exchange network.

Active member of the Senior Leadership Team responsible for developing and implementing provider network development strategies for new market implementations, market expansions and network management. Identify Strategic Partners that could provide services to our member or expand services to meet company objectives. Create and implement program strategies to support company business goals and objectives.Optimize existing and new provider networks for the purpose of delivering quality, integrated and cost effective care to members and providers. Ensure that provider contracting rates and terms meet the business objectives. Implement formal processes for establishing and monitoring provider contracting objectives for each market, including rates, terms and network composition. Ensure that provider contracts meet targeted budgets, network characteristics and other metrics. Develop provider network incentive programs designed to drive changes in provider behavior, leading to improved Medical Benefit Ratios (MBR) and improved provider satisfaction. Lead collaborative efforts to develop provider servicing model to increase provider and member satisfaction. Collaborate with corporate reimbursement leaders to develop and implement reimbursement methodology strategies that are consistent with business objectives.

Ensure that designated clients receive consistent, high-quality operations support. Dedicated to clients or region based on client size, geography, and complexity. Partner directly with our clients to identify and triage operational issues, and deploy their team of 3-5 operational experts to do root cause analysis and solution any operational problems that might arise. While acting as an advisor and trainer to their team. Work collaboratively across the enterprise to ensure client solutions are thoughtfully implemented. Develop cross-functional operations capabilities so everyone on the team is a true “ops athlete” – capable of driving to solutions across any number of root causes. Manage annual benefit updates and new product roll-outs for clients. Mange client satisfaction and customer retention – managing client expectations in line with regional operational priorities, and maintaining regular communication throughout the solutioning cycle. Participate in the annual planning process for clients to define operational priorities. Partner with internal stakeholders to ensure strategic and operational priorities and communications to the client are consistent and in sync.Collaborate with leadership to define, document and review client business requirements, ensuring new requests are in line with contractual agreements or identifying opportunities for upsell. Coordinate with other Regional Operations leaders and Regional COO to identify best practices and support ongoing improvements, including triage of clinical/quality issues into the Regional Clinical and Quality Operations Lead. Work closely with other leaders to identify operational issues that span multiple regions, and potentially spearhead cross regional initiatives.

Responsible for developing and implementing behavioral health network development strategies for new market implementations and market expansions. Develop behavioral health strategies to support company business goals and objectives. Project management lead for new market and/or current market behavioral health expansion and implementations to ensure network adequacy compliance. Develop and implement new and on-going strategies that will guide behavioral health contracting efforts in each of Medicaid targeted markets. Optimize Medicaid existing and new provider networks for the purpose of delivering quality, cost effective care to Medicaid members and providers. Serve as behavioral health contracting and reimbursement subject matter expert for health plans. Provide direction to other staff and consultants in the recruitment and contracting efforts. Ensure that provider contracting rates and terms meet the business objectives for Medicaid. Lead collaborative efforts with the Behavioral Health Medicaid management team to ensure contracting strategies are implemented effectively. Implement formal processes for establishing and monitoring provider contracting objectives for each market, including rates, terms and network composition. Ensure that provider contracts meet targeted budgets, network characteristics and other metrics. Develop behavioral health incentive programs designed to drive changes in provider behavior, leading to improved Medical Benefit Ratios (MBR) and improved provider satisfaction. Lead collaborative efforts to develop behavioral health provider servicing model for corporate and local health plans. Collaborate with corporate reimbursement leaders to develop and implement reimbursement methodology strategies that are consistent with business objectives. Lead collaborative efforts to develop behavioral health provider servicing and contracting training resources.

AMERIGROUP - Wellpoint Medicaid Business UnitResponsible for health plan operations policies, best practices, CMS and State regulatory compliance, resolution of claims and contract issues, and NCQA compliance. Develop and build strong working relationships with plan senior management and corporate support areas to assist in meeting the goals of the organization. In addition, demonstrate high levels of flexibility by managing health plan projects based on strategic priorities. Also, responsible for identifying and prioritizing health plan opportunities for improvement in the areas of efficiency, effectiveness and regulatory compliance.

AMERIGROUP - Wellpoint Medicaid Business UnitResponsible for the management of the Provider Services and Contracting Team for Behavioral Health and Ancillary Services, Ancillary services include but not limited to, Long Term Care, Home Health, Infusion, DME, Free Standing Outpatinet Centers (Dialysis, Oncology, etc), and Ambulatory Surgery Centers. Health plan subject matter expert for behavioral health services contracting and practice management, including behavioral health network expansion and Community Mental Health Center network re-contracting to different payment methodology. Implements and monitors strategic initiatives outlined in the health plan’s business plan. Evaluate and monitor the provider network to ensure adequate member access and state contract compliance. Health plan representative to state, advocacy trade, and other organizations. Develop and implements provider recruitments strategies which support the goals of the health plan.

Over-see the daily operations of two inpatient psychiatric facilities. Responsible for compliance with state, federal, and JCAHO standards/regulations. Manage budget and planning for behavioral health programs. Coordinate and facilitate quality assurance and performance improvement iniatives. Directly responsible physician relations. Direct program responsibilities inlcude crisis evaluation department, discharge planning, and clinical integration.

Responsible for evaluating and assessing compliance with federal, state, and JCHAO standards for the healthcare system. Facilitated projects and developed polciies that would ensure complaince with requirements. Facilitated quality and performance improvement iniatives. Coordinated survey readiness program. Assisted in development and implementation of Continuous SErvice Readiness Program.

Responsible for evaluating and assessing compliance with federal, state, and JCHAO standards for the behavioral healthcare organization. Facilitated projects and developed polciies that would ensure complaince with requirements. Facilitated quality and performance improvement iniatives. Coordinated survey readiness program.