Director of Provider Network Development: WEA Trust

Position Summary

The Director of Provider Network Development assists in the provision of excellent service to internal and external customers by working with the Member Health & Provider Services Director and other department staff to develop and maintain effective relationships with all providers that result in convenient access, high quality, and cost-effective services rendered to plan participants and financially competitive plan rates.

Objectives

to establish and implement favorable financial agreements with providers throughout the state for direct services rendered to participants. The Director of Provider Network Development identifies large and/or critically important medical providers, integrated provider systems, and provider networks with whom to develop mutually beneficial relationships; assesses the feasibility and cost-effectiveness of potential contracted providers and networks; negotiates and contracts with providers and provider networks; ensures the WEA Trust (the Trust) work units have complete, timely, and accurate information about provider networks and contractual provisions; periodically analyzes contractual language, as well as the parties’ obligations and overall relationships, to ensure regulatory compliance and preserve adequate network access; and renegotiates contracts where improvements are needed. (60%)

to ensure the cost-effectiveness and performance of the trust’s provider contracts. The Director of Provider Network Development monitors providers’ contract performance, analyzes relevant reports, identifies reporting and systems deficiencies, and recommends reporting and system enhancements so contracts can be administered accurately and ongoing provider performance can be effectively measured. The incumbent also explores options for minimizing administrative costs associated with provider and network contracts. (15%)

to ensure superior customer service to plan participants and efficient company operations through development and sustenance of effective working relationships with contracted medical providers, integrated provider systems, and provider networks. The Director of Provider Network Development regularly communicates with assigned provider partners to respond to and resolve these providers’ questions, concerns, or complaints; shares intra- and interdepartmental feedback about problematic partnership issues, such as those involving inefficient internal processes or inappropriate patterns of decisions cumbersome to the Trust staff and participants; and effects necessary changes by adding, changing, or removing contractual requirements, standard operating procedures and work flows, computer system enhancements, and/or staff training. (15%)

to maintain financially competitive health and dental plans through monitoring and evaluating the adequacy of the trust’s provider reimbursement. The Director of Provider Network Development continuously evaluates provider reimbursement and recommends, develops, and implements new provider reimbursement and incentive/risk models as necessary. The incumbent also develops and maintains expertise in reimbursement methodologies to ensure the Trust’s reimbursement practices fulfill its objectives. (10%)

Qualifications Required for Appointment

To be considered for appointment to this position, the applicant must demonstrate the following:

Commitment to excellence in customer service and other Trust values, including support for the value of labor unions and cooperative insurance programs.

Successful provider contracting experience, including:

Excellent provider relations experience and thorough knowledge of managed care practices and provider contracting, either in a provider or payor capacity, including knowledge of provider systems in Wisconsin and elsewhere, provider reimbursement methodologies and coding and billing procedures, and related concepts and terminology.

Thorough knowledge of insurance terminology, concepts, and benefits issues.

Excellent verbal communication skills, including the ability to listen effectively, persuasive negotiation skills, and the ability to communicate technical issues to individuals and in presentations to groups.

Ability to comprehend and interpret managed care contract terminology and knowledge of quantitative analysis related to provider reimbursement.

Thorough understanding of the Trust’s member demographics or the willingness and the ability to gain.

Excellent written communication skills, including the ability to compose clear, concise, and persuasive contract provisions, correspondence, and narrative reports that communicate messages consistent with the Trust’s policies, plans, and provisions to both internal and external audiences using appropriate tone, grammar, and word usage.

Knowledge of personal computers utilizing Microsoft Word and Excel.

Excellent decision-making skills, including appropriate problem identification and analysis, idea generation, information research and organization, and conclusion determination.

Ability to independently establish goals and manage resources to achieve goals. Excellent organization skills, including the ability to appropriately prioritize work, efficiently and effectively coordinate multiple tasks simultaneously, meet designated deadlines, and achieve expected results.

Ability to develop and maintain effective, collaborative relationships with customers, stakeholders, and staff at all levels of the organization.

Willingness to regularly travel throughout Wisconsin and surrounding areas, including occasional overnight travel, a valid Wisconsin driver’s license, and a satisfactory driving record.

Initiative, including the ability to research, suggest, and initiate improvements and efficiencies in processes, procedures, and contract language.

Flexibility to work the number and schedule of hours needed to accomplish regular and ad hoc job responsibilities.

Evidence of excellent performance in present and prior positions.

Qualifications Required for Successful Performance

For successful performance in this position, the incumbent must demonstrate the following:

Excellent performance of all of the foregoing duties assigned.

Thorough understanding of the mission and the political context of the work of the Trust.

Ability to improve effectiveness and efficiency within the domain of the incumbent’s assigned responsibilities.

Commitment to continued learning in all areas relevant to the responsibilities of this position.