Senior Director of Provider Network Operations

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. 

Position Overview

The Senior Director of Provider Network Operations oversees all aspects of the provider operations, provider relationship management, provider education, provider enrollment, credentialing, provider data integrity and provider regulatory compliance. The Senior Director is a strong advocate for provider focus for the enterprise as well as provider relations and seamless provider operations.

• Oversee staff that has day to day responsibility for managing the relationships that supports the
• MetroPlus Provider Network, serving as escalation point for internal staff and external contacts regarding resolution of highly complex or unusual business problems that affect major contract functions, performance, or relationships.
• Ensures provider education (new provider orientation, on-going provider visits and meetings, etc.,) activities are done in a timely and cost-effective manner to continuously improve relationships with network providers.
• Ensure that relationships with providers are appropriately monitored and maintained to drive high provider satisfaction
• Meet regularly with providers at Joint Oversight Committee meetings to address all financial, operational, quality and contractual issues.
• Monitors and reviews provider satisfaction results and makes recommendation for improvements
• Collaborates with internal departments to assess provider experience and identify areas of opportunity
• Ensure timely responses to regulatory agencies (i.e., NYSDOH, DFS) in response to all Provider Network regulatory and compliance issues
• Keeps abreast and maintains familiarity with industry and government program (Medicare and Medicaid) trends, regulations, legislation, and payment rules and reimbursement methodologies.
• Builds a high-performance environment and implements a people strategy that attracts, retains, develops and motivates their team by fostering an inclusive work environment and using a coaching mindset and behaviors; communicating vision/values/business strategy; and managing succession and development planning for the team.
• Manages, trains, coaches, and develops staff across the Provider Network Operations departments
• Develops staffing models and monitor capacity/capabilities of teams across the Provider Network Operations departments
• Leads Teams in a manner that promotes the ongoing growth and expanded knowledge of associates
• Establishes and reports key metrics to track department performance
• Supports team members in the identification of operational barriers and creative problem resolution for improved processes and expanded use of technology
• Work with all parties to adequately address and resolve data discrepancies to reduce financial and compliance risks to the plan
• Provide performance improvement reports based on analyses of compliance and/or audit findings
• Develop and implement approved modifications to workflows, policies and procedures to improve performance
• Oversees the research, analysis, and resolution of complex problems with claims development and finalization.
• Support Account Management team with regular and ad-hoc provider data requests
• Conducts special projects including business analyses, strategic planning, and implementation efforts on new business acquisitions and changing corporate requirements.
• Manages the overall budget in support of the responsibilities of the areas and corporate initiatives and responsibilities.
• Perform other responsibilities as assigned

• 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 with increasing responsibility including staff management 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.
• Familiarity with provider community and health care marketplace trends and superior knowledge of NYS hospital reimbursement and managed care laws and regulations
• Data management, data analytics, quality assurance, and project management skills required. Ability to efficiently standardize and reconcile disparate data effectively.
• Strong quantitative skills, including the ability to identify trends/analyze
• Effective oral, written, and interpersonal communication skills required.

Professional Competencies:

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