Supports network and quality strategy.
Implements and provides oversight of performance related projects as corporate best practices and strategy have identified.
Uses data and analysis tools to identify opportunities for improved performance and collaborates with peers to develop intervention strategies of which can be applied to the provider action plans.
Conducts meetings with providers to review performance data and discuss areas of opportunities to strengthen provider partnerships in conjunction with PNM and CMO as applicable.
Tracks and prepares reports on action plans and outcomes of initiatives that advance provider VB performance per year.
Provides cross functional collaboration with PNO, PNM, and Quality programs to achieve goals and objectives.
May assist with scheduling appointments for members and attend member outreach meetings in addition to provider meetings.
Value-based contracts with providers as it relates to HEDIS, withhold measures, TCOC performance metrics and other quality-based programs.
General Operational Knowledge related to provider satisfaction, education and communication with a fundamental understanding of operational items such as claims coding, payment integrity, provider data, credentialing, appeals disputes etc. applicable to State, Federal and STARS standards to ensure compliance.
Education & Experience
Associate's degree required
Bachelor’s degree in healthcare administration or similar field required.
5 or more years of experience in provider networking if no bachelor's degree.
3 or more years of experience as an Account Executive, TCOC, understanding of reimbursement methodologies to include risk or VBC.
Understand quality and provider performance reporting and HEDIS or other quality measures.
Skills & Abilities
Healthcare regulations, reimbursement models and quality measures.
Possesses strong analytical skills to interpret and prepare provider performance data.
Knowledge of healthcare regulations, reimbursement methodologies, value-based contracting, and quality measures, including HEDIS and total cost of care.
Ability to identify performance gaps, develop actionable improvement strategies, and monitor outcomes.
Proficiency in preparing and presenting provider performance reports to internal and external stakeholders.
Strong written and verbal communication skills, including the ability to explain complex data clearly.
Ability to build collaborative relationships with providers, account executives, clinical leaders, quality teams, and network management partners.
Strong project management, organization, and follow-through skills.
Knowledge of provider operations, including claims coding, payment integrity, credentialing, provider data, appeals, and disputes.
Ability to lead provider meetings, facilitate performance discussions, and create provider action plans.
Proficiency with data analysis, reporting, and Microsoft Office applications.
