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Vice President of Provider Network Operations

Job Ref: 73866
Category: Professional
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $200,000.00
Salary Range: $200,000.00 - $230,000.00

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlusHealth 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, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview

The Vice President of Provider Network Operations has direct responsibility over credentialing, provider data management, regulatory compliance, training and network reimbursement resolution.

Job Description

  • Responsible for primary source credentialing verification, delegated credentialing, provider enrollment and ensure compliance with CAQH standards, state and federal regulations requirements.
  • Analyze and implement process improvements to enhance efficiency of credentialing; Conduct on-going program evaluations and audits of data integrity.
  • Oversee provider training to internal and external stakeholders.
  • Data steward who owns the accurate collections, maintenance, and dissemination of all provider data.
  • Identify data anomalies and provide sustainable corrective action plans such as duplicate record reconciliations, demographic updates, etc.,
  • Coordinate with internal matrix partners (e.g. Credentialing, Quality, IT) to standardize and develop policies and procedures for Network Operations.
  • Assess network by factors such as provider type, specialty, health system, and geographic area for adequacy and develop strategies for long-term sustainability.
  • Monitor access and availability and other routine/ad-hoc regulatory provider surveys/certifications and ensure regulatory compliance.
  • Work with all parties to adequately address and resolve data discrepancies to reduce financial and compliance risks to the plan.
  • Review and communicate network reimbursement issues, adhoc claims projects, perform root cause analysis and identify strategies to reduce claims payment discrepancies.
  • Oversee external audits and regulatory reporting (e.g. PNDS, CMS, etc.) related to provider network; assist with other audits and reviews as needed where network metrics are required.
  • Provide performance improvement reports based on analyses of compliance and/or audit findings.
  • Develop and implement approved modifications to workflows and policies and procedures to improve performance;
  • Oversees the research, analysis and resolutions of complex problems with claims development and finalization.
  • Provide day-to-day oversight of network operations.
  • Research and recommend automation solutions where feasible.
  • Support Account Management team with regular and ad-hoc provider data requests.
  • Perform other responsibilities as assigned.
  • Establishes plans of action, allocation of staffing resources, scheduling, etc., to ensure operational efficiency consistent with corporate and departmental goals.
  • Conducts special projects including business analyses, strategic planning, and implementation efforts on new business acquisitions and changing corporate requirements.
  • Coordinates and supervises operational analyses and implementation support on major workflow and activity modifications.
  • Implements changes for operational methods, procedures, policies and workflows affecting the assigned network operations staff.
  • Manages the overall budget in support of the responsibilities of the areas and corporate initiatives and responsibilities.

Minimum Qualifications

  • Master’s Degree in public health, business, or related field.  Managed care experience preferred.
  • Minimum of 10 years of combined network management, credentialing or regulatory affairs.
  • experience, operations, claims preferably in a managed care or insurance environment.
  • An equivalent combination of training, education and experience in related fields and educational disciplines.
  • Data management, data analytics, quality assurance, and project management skills required.  Working knowledge of Medicare and Medicaid required. Ability to efficiently standardize and reconcile disparate data effectively.
  • Effective oral, written, and interpersonal communication skills required.

Professional Competencies:

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