Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
JOB SUMMARY:
The Vice President, Network Management is responsible for the strategic direction and oversight for all non-clinical Provider-facing functions including Provider Contracting, Provider Relations, Credentialing, and Network Administration. Directs the strategic development and maintenance of Community's network of Providers for all programs and lines of business. Leads the development, implementation and maintenance of a robust Provider Engagement Program that rewards and incentivizes Providers to achieve Community's goals, including the movement of Community's provider contracts to a value-based payment methodology. Responsible for the Provider Education Program for all of Community's Provider Networks. Ensures accurate, timely and compliant communication with Providers regarding claims payments.
Leads the development of network strategies and innovative reimbursement and risk
models to align provider incentives around performance. Ensures the network
composition includes an appropriate distribution of provider specialties to achieve
network adequacy requirements.
Negotiates and/or oversees the negotiation of hospital, physician and ancillary
provider contracts that allow achievement of company financial performance targets
through existing and innovative compensation methodologies. Works with the
Finance analytics team, Medical Management workgroup, and Executive Team as
needed to make essential data-driven decisions.
Monitors the financial performance of the contractual arrangements
Ensures all operations, communications, contract documents and daily interactions
with providers remain compliant with regulatory and accreditation standards
Ensures an accurate, timely, and frequently maintained Provider Directory
Ensures timely and accurate submission of regulatory and compliance reports
associated with the Network Contracting and Management
Monitors compliance with contracting standards, reimbursement methodologies and
the application of model contract language
Works closely with Configuration and Provider Data to oversee contract set-up and
configuration to ensure accurate claims adjudication
Establishes and updates, as needed, CHC's provider contracting and relations
policies and procedures, CGHC provider contractual materials and CGHC's provider
manual. Ensures providers are effectively informed and updated as necessary
Monitors and reports significant developments occurring within the provider
community and assist in developing a strategic plan to mitigate risks and capitalize
on opportunities
Assists CHC and CHC-contracted vendors with necessary provider outreach related
to claims submission efforts and medical record retrieval as needed to support EDGE
reporting and risk adjustment activities.
Directly supervises leadership positions in the following functions, and indirectly all
departmental staff:
a. Contracting
b. Provider Relations
c. Value Based Contracting
d. Network Administration
Develops annual departmental budgets and monitors expenditures to meet
administrative cost targets.
Actively contributes to achievement of departmental goals, as identified in
Department's annual business plan, including specific departmental process
improvement plans.
Reports to Position Title: EVP, Chief Operating Office
MINIMUM QUALIFICATIONS:
Education/Specialized Training/Licensure:
Bachelor's degree in healthcare, Business, Marketing or related field; MBA, Master of Public Health or Health Administration strongly preferred.
Work Experience (Years and Area):
Ten years in a Patient Care or Managed Care organization.
Experience in contract negotiation, provider relations, network administration and claims processing/audit required.
Management Experience (Years and Area): Five years of management experience
Software Operated: Microsoft Office (Word, Excel, Outlook)
OTHER REQUIREMENTS:
- Experience in developing and implementing strategies and objectives for assigned areas of oversight, assuring alignment with organizational strategies and objectives.
- Ability to develop and manage departmental budgets, achieve financial targets.
- Demonstrated ability to proactively identify and analyze the root cause of challenges and concerns, breaking down a systemic issue into component parts, addressing bottlenecks and/or breakdowns.
- Experience with claims processing software and CRM systems required. Experience with QNXT, Salesforce, PeopleSoft and PowerBI preferred.
- Contract negotiation skills required.
- Excellent communication skills, including communication with providers and regulatory oversight agencies.
- Demonstrated flexibility and ability to quickly adapt to new situations and challenges.
- Skilled at delegation, management and development of staff.
- Ability to inspire confidence and create trust.
Work Schedule: Hybrid
EMPLOYEE SUPERVISED: Professional and Clerical Staff
