Director of Provider Maintenance
MetroPlus Health Plan - New York City, NY
Apply NowJob Description
About NYC Health + HospitalsMetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus'' network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. Position OverviewThe Director of Provider Maintenance is responsible for management of the Provider Maintenance function and its interrelationship with Providers and other business units of the Health Plan. This role is responsible for managing a Provider Data Management business and IT solution focused on creating the MetroPlusHealth System of Reference for provider demographic data used for business and regulatory reporting. The role manages the strategic direction, implementation management, governance, and data stewardship.Salary commensurate with education and experience.Job DescriptionDesign and oversee an efficient, customer centric Provider maintenance operationIn conjunction with MetroPlusHealth IT, and organizational leadership, manage the direction and strategy for the Plan Provider Data Management Program focused on becoming the Heath Plan source of data, reporting and information related to all networks, across all Boroughs and lines of business, including H&H, community and vendor Provider data Serve as the Health Plan Data Steward for the Provider Data domain Support Plan operations in various capacities where provider data has an impact including claim processing, credentialing, contract configuration, and network analyticsAssist and oversee claims system configuration, testing and workflow of Provider information including but not limited to provider fee schedules, contract entry, and claims processes Track and trend issues to identify problems; determine root causes and implement effective solutions Ensure compliance with Provider contract guidelinesEnsure accurate, complete and timely data collection and disposition of informationDevelop and document departmental policies and procedureImplement systems to ensure ongoing compliance with regulatory and when applicable, accreditation standardsEstablish network adequacy monitoring processes and tools Produce and report departmental key process and outcome indicatorsParticipate in evaluation of Provider interfacing IT systems and identification/selection of new systemsInvestigate Provider issues in collaboration with other MetroPlusHealth departments, implementing policies, procedures and systems to reduce incidence of recurring issues Ensure Plan has resources and capability to perform in person, telephonic and automated provider recruitment, orientation, and service calls Collaborate with provider relations and other departments as indicated to design and implement activities to maintain and improve satisfaction of the provider networkMeet with participating providers to identify service improvement opportunities Identify opportunities to continuously improve the data discovery and onboarding processCommunicate member complaints to Providers and vendors ensuring timely and appropriate responsesEnsure acknowledgements, timely responses, corrective actions are sent in response to Provider complaints Establish audit procedures to monitor accuracy of data input and effectiveness of team performanceResponsible for directory data solutions to meet the needs of key regulatory and business requirementsMonitors state, federal and accreditation regulatory requirements for directories, evaluates MetroPlusHealth directory, and work with internal departments on gap remediation.Participate in regulatory, security, compliance and other external auditsMaintain knowledge of industry trends, best practices and protocolsAll other duties as assignedMinimum QualificationsBachelor''s degree required, Master''s in health care administration or a related area of study preferredMinimum of seven (7) years managed care experience including three years in a managerial capacityExperience with and understanding of claims management system architecture including fee schedule configuration and contract set up Proven record of success improving Provider relations and satisfaction Excellent oral and written communication skillsKnowledge of Medical Terminology Excellent organizational and analytical skillsDetail-orientedProficiency in computer applications including Microsoft word and ExcelProfessional CompetenciesIntegrity and TrustCustomer FocusFunctional/Technical SkillsWritten/Oral Communication
Created: 2021-11-29