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Job Details

Director of Provider Maintenance

Job Ref: 66709
Category: Professional
Department: PROVIDER CONTRACTING
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $14,000.00
Salary Range: $140,000.00 - $147,000.00

About NYC Health + Hospitals

MetroPlus 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. 

Salary commensurate with education and experience. 

Position Overview

The 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.

Job Description

  • Design and oversee an efficient, customer centric Provider maintenance operation
  • In 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 analytics
  • Assist 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 guidelines
  • Ensure accurate, complete and timely data collection and disposition of information
  • Develop and document departmental policies and procedure
  • Implement systems to ensure ongoing compliance with regulatory and when applicable, accreditation standards
  • Establish network adequacy monitoring processes and tools 
  • Produce and report departmental key process and outcome indicators
  • Participate in evaluation of Provider interfacing IT systems and identification/selection of new systems
  • Investigate 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 network
  • Meet with participating providers to identify service improvement opportunities 
  • Identify opportunities to continuously improve the data discovery and onboarding process
  • Communicate member complaints to Providers and vendors ensuring timely and appropriate responses
  • Ensure 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 performance
  • Responsible for directory data solutions to meet the needs of key regulatory and business requirements
  • Monitors 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 audits
  • Maintain knowledge of industry trends, best practices and protocols
  • All other duties as assigned

Minimum Qualifications

  • Bachelor’s degree required, Master’s in health care administration or a related area of study preferred
  • Minimum of seven (7) years managed care experience including three years in a managerial capacity
  • Experience 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 skills
  • Knowledge of Medical Terminology 
  • Excellent organizational and analytical skills
  • Detail-oriented
  • Proficiency in computer applications including Microsoft word and Excel

Professional Competencies

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical Skills
  • Written/Oral Communication