Manager, Network and Medical Cost
The Manager, Network and Medical Cost is responsible for managing specialist network by maintaining and developing Florida areas. Provides service and education to network specialists. Achieves company targets through the implementation of network improvement plans. Works in conjunctions with the Network Director.
ESSENTIAL JOB DUTIES/RESPONSIBILITIES:
- Builds and maintains effective long-term relationships and high level of satisfaction with key specialists.
- Conducts site visits to service providers, resolve issues, educate staff/providers on policies and certify specialists.
- Establishes consistent and strong relationship with specialist’s provider offices.
- Identifies network gaps.
- Supports Network development by providing utilization reports, pharmacy profiles, ER contingencies, Frequent Flier Reports and other analytics available to improve/maintain outcomes.
- Identifies root cause of problems and trends and participates in developing solutions.
- Works with Provider's staff and organization staff to resolve the issue and monitor recurrence.
- Special projects as assigned or directed.
- Strategizes for membership growth and retention.
- Collaborates with Referral Manager to develop referral protocols.
- Other duties as assigned and modified at manager’s discretion.
KNOWLEDGE, SKILLS AND ABILITIES:
- Excellent influencing and negotiation skills.
- Ability to explain complicated financial terms and utilization data to physicians/staff.
- Excellent written, verbal and public speaking skills.
- Ability to understand, interpret and communicate all types of provider and regulatory contracts.
- This position requires up to 10% of travel nationwide.
Additional Job Description
EDUCATION AND EXPERIENCE CRITERIA:
- Bachelor's degree.
- Three (3) + years Provider Relations experience or similar background.
- Three (3) + years’ experience in Medicare, with knowledge of CMS and state regulations.
- Three (3) + years’ experience in HMO/PPO.
- Pharmacy, healthcare, or provider relations experience.
- Advanced MS Word and Excel.