Dir, Ntwk Ops Engagement

Profile

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, , IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Director will focus on operational oversight and service accountability for a portfolio of key and large groups and health systems within an assigned geographic market/region. Responsibilities include servicing issues, leading operational reviews and overseeing solution design and service recovery efforts with providers. This role will support Tri West's MVS team with healthcare access needs, assist with engaging providers to support Value Base Care initiatives, and partnering with Network Contracting and Subcontractor teams to advance strategic and operational initiatives for both VA (CCN) and DHA (TRICARE).

Responsible for the performance of the network within the designated market in conjunction with other teams to include:
Provider Network Managers, Military & Veteran Services (MVS), Provider Relations, Data, Claims, Credentialing, and Project Managers. Ensures adherence with government operational manuals, monitors network shortfalls, and resolves access issues with directly contracted providers throughout the assigned region. Facilitates resolution of escalated provider issues and promotes Tri West Corporate initiatives. Reports to the Vice President of Provider Network Operations.

• Bachelor's degree in Business, Health Care Administration or equivalent experience
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 7+ years of leadership and/or account management experience in managed care, a health plan, or a health system, including provider network or payer-provider relationship management
• Working knowledge of provider contracts with health systems, hospitals, or large provider groups, including reimbursement, discounts, and contract terms
• Demonstrated success resolving complex conflicts, driving results with internal and external partners and stakeholders, and proactively managing issues
• Experience and fluency in health plan credentialing, provider data systems, healthcare analytics, and/or performance management

• Experience negotiating with multi-state health systems or national provider groups
• Experience with government healthcare programs (VA CCN, TRICARE, Medicare)
• Experience with in managed care, provider network operations, or related healthcare environments, including provider network delivery, network data management, credentialing, provider services, contracting, project management, claims issue resolution, or other related provider operations functions
• Knowledge or experience with military culture or military healthcare
• Familiarity with Medicare, Medicaid, or Commercial payment and claims processing rules

• Develops and maintains relationships with providers and customers within a designated market of states.
• Ensures that network adequacy objectives are attained in all geographic areas of responsibility.
• Lead partnership, advocacy, and service delivery for a portfolio of Health Systems across multiple states, along with large Provider Group strategic partnerships and National providers
• Support MVS Field Staff and Military Treatment Facility/VA Medical Center network/provider needs in their regions. Could include triangulating key discussions with providers/field, reporting and monitoring access to services, as well as visibility in person at outreach engagements.
• Measures performance of all defined Service Level Objectives.
• Monitors network in coordination with other Provider Services Directors to ensure adequacy is being achieved and institutes corrective actions to address shortfalls in network.
• Directs workflows tied to resolving all network issues within assigned territories across functional teams within the organization.
• Monitors and ensures dotted-line teams are following through on resolution of routine and escalated provider issues.
• Communicates information regarding market needs, competition, and industry trends to management team.
• Maintains client confidence and ensures confidential information is protected.
• Works with Network Strategy and Provider Contracting leadership to…