Medicare Provider Network & Quality Manager

Job Description

Must be located in Ohio OR Michigan

A bit about this role:

This is a key role in our organization. This role will require a strong understanding of Medicare Advantage quality programs, including CMS STAR measures, with the ability to work collaboratively with providers to identify and close clinical care gaps, improve quality performance, and support initiatives that enhance member outcomes and overall plan performance. Additionally, this role will be responsible for network development and management along with servicing for an assigned geographic area.

The ideal candidate will possess 5+ years experience in recruiting and managing provider networks along with negotiating, reviewing and amending contracts. This experience will include thorough knowledge of contracting with physicians and physician groups, integrated delivery systems, health systems, and ancillary providers using various payment methodologies including fee-for-service and value based / risk. Ideally, the candidate will possess a very high level of business acumen and be able to exhibit it both internally and externally to a wide variety of audiences.

Innovation, independence and confidence are key competencies that need to be exhibited.

Responsibilities & Impact will include:

• Development, maintenance and management of an adequate provider network in assigned geographical area

• Maintaining relationships and all provider relations activities in assigned geographical area, including negotiating and renegotiating contracts with providers as assigned

• Engage internal subject matter experts and providers to identify opportunities to improve provider / member cost and quality performance

• Monitoring of various reports to insure all necessary compliance requirements are met and maintained Reporting to leadership current status, risks, and potential opportunities in area of responsibility on a regular basis

• Supporting the overall Network Team as required to achieve success for Devoted Health

• Supporting assigned groups to improve performance in CMS STAR measures, including educating providers and their staff on STAR measure requirements, identifying performance gaps through data analysis, coordinating with internal quality teams to implement improvement initiatives, reviewing provider-level performance reports, and working directly with practices to implement workflows and best practices that improve quality outcomes, member satisfaction, preventive care compliance, and clinical documentation accuracy

• Utilizing performance dashboards and reporting tools to track STAR measure performance, HEDIS metrics, and other quality indicators, proactively engaging providers whose performance falls below targets and collaborating on action plans to improve results

• Partnering with internal quality, clinical, and analytics teams to interpret STAR performance reports and translate insights into actionable strategies for providers, ensuring alignment with organizational goals and CMS quality improvement priorities

Required skills and experience:

• 5+ years negotiating provider contracts including physician / provider group contracts with multiple payment methodologies including value based/risk

• Provider servicing experience

• Solid ability to navigate either Google or MS Suite of products High School Diploma or equivalent minimum

• Experience in CMS STAR measures

• Experience and relationships in the local market

• Unrestricted driver's license to verify your eligibility and capability to fulfill the driving responsibilities associated with the position

Desired skills and experience:

• Ability to make quick, independent decisions

• Mutually beneficial negotiation skills

• Strong project management skills

• Attention to detail

• Ability to analyze financial and performance reports and identify trends/variances“

• Understanding impacts of decisions on network as a whole

• Extremely effective oral/written communication skills

Salary: $80,000 - $110,000 / year

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium

• Generous paid time off

• $100 monthly mobile or internet stipend

• Stock options for all employees

• Bonus eligibility for all roles excluding Director and above;
  Commission eligibility for Sales roles

• Parental leave program

• 401K program

• And…