Director, Provider Management

Location: Laguna Hills, California, United States

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Remote Opportunity: 0

Requisition Number: 3814

Position Title: Director, Provider Management

External Description:

JOB SUMMARY: 

The Director, Provider Management strategically analyzes, manages, and reports on the provider network and related activities regarding DentaQuest’s suite of programs (Medicaid, Medicare Advantage, Marketplace and Direct to Consumer and Commercial and any blend of dental products). The Director, Provider Management is charged with the development and oversight of access, cost, and quality measurements to ensure network compliance, client satisfaction, sound provider performance, and improved clinical outcomes. The PMD maintains ultimate oversight of assigned provider management staff, and therefore provides clear direction, ongoing education and implement daily activity monitoring tools for reporting purposes. This position interfaces with multiple internal operational areas, but will also interact face to face with clients, representing DentaQuest as local leadership and the network Subject Matter Expert.

 

PRIMARY JOB RESPONSIBILITIES:

  • Provide support and direction to Provider Management team or direct-report staff to ensure appropriate allocation of resources to meet multiple deliverables and participate in wide range of network focused initiatives
  • Approve and monitor special requests, retroactive adjustments, reimbursement, and contract exceptions
  • Collaborate with Provider Management leaders to monitor provider networks using supplied tools and reports to ensure compliant quality networks
  • Proactively research competitors’ provider panels; fee schedule and reimbursement methodologies; policies and procedures; tools and technology; processes; etc. within assigned markets and make recommendations to meet or exceed competition
  • Build and maintain relationships with leadership within client network staff, local dental associations, FQHCs, Public Health, large group practices and other key stakeholders
  • Collaborate with Client Engagement Regional Director and California sales and account management team to service network needs for commercial, State and/or health plan clients via on-site meetings, conference calls, and day-to-day interaction.
  • Direct Provider Management team on the appropriate preparation of client network audit, CAP and ad hoc report documents
  • Oversee provider management activities and other projects related to the dental provider network
  • Ensure internal and external network reports are prepared and delivered accurately and timely by self and/or designated staff
  • Develop solutions to improve participating provider satisfaction and innovative approaches to advance recruitment strategies to attract providers to join various line of business networks
  • Develop solutions to improve tracking and updating the most current contracted provider data to reconcile with States’ Master Provider Files
  • Develop and maintain provider reimbursement schedules and models in line with cost of care goals, market research and profitability objectives of clients and the DentaQuest organization
  • Aid in developing network and provider relations related Request for Proposal (RFP) responses
  • Draft Provider Agreements, Restated Agreements, Amendments and other communications as needed
  • Serve as Network SME when meeting with client leadership
  • Organize workflow with other departments to ensure efficient, timely and accurate outcomes
  • Select and enhance the development of all reporting employees by providing appropriate training, coaching and evaluation consistent with the DentaQuest culture and the assigned functions
  • Coordinate and implement performance management strategies for reporting team members and design reports to effectively manage staff performance and assigned projects/deliverables
  • Provide education and direction to Provider Management teams to utilize reports and tools for the purpose of analyzing their assigned network performance and trends
  • Work collaboratively with sales and underwriting to achieve loss ratio goals through effective network recruitment strategies
  • Work collaboratively with marketing to create provider communication and branding in assigned markets
  • As a member of the leadership team, provide input to the strategic management of DentaQuest to ensure that short term financial and long-term corporate objectives are achieved, via network related initiatives
  • Develops provider incentive programs to boost access to care, reward quality work that result in better outcomes
  • Coordinate and implement appropriate performance management strategies for team members to include:
    • Assist in the hiring process, including interviewing candidates
    • Assist, train and motivate team members
    • Evaluate and measure effectiveness of team members
    • Assist in preparation of performance and wage evaluations in accordance to company policy
    • Responsible for attendance and company approved time off for team members
    • Participate in the determination and implementation of Performance Improvement Plans and performance management initiatives.
  • Oversee development and supervision of California credentialing policies, procedures and database, including day-to-day management of staff, to ensure state and federal regulatory compliance.
  • Other duties as needed or required.

 

JOB QUALIFICATIONS:

 

Required:

 

  • Bachelor’s degree required
  • 7 years’ experience in healthcare practice or managed care
  • 5 years’ supervisory/management experience
  • Ability to analyze provider data and make improvement and program recommendations
  • Excellent oral and written communication skills
  • Strong negotiation, analytical and presentation skills
  • Project management and process improvement skills
  • Ability to prioritize and organize multiple tasks while remaining organized with multiple interruptions
  • Ability to meet numerous tight deadlines

 

Preferred:

 

  • Knowledge of provider network reimbursement models and contracting
  • Proficiency with general computer software (Excel, MS Word, and Access a Plus)

 

PHYSICAL DEMANDS:

  • Incumbent must be able to communicate
  • Requires overall light physical effort (up to )
  • Manual dexterity and sitting are required in carrying out position own position responsibilities (i.e. use of personal computer).
  • Ability to travel or move about within and outside serviced facilities
  • Incumbent works primarily in either a private or shared office

 

 
  

 

The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria necessary to successfully perform this position.

 

City: Laguna Hills

State: California

Community / Marketing Title: Director, Provider Management

Company Profile:

We believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system – from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.

Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it. 

To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and delivering measurable outcomes for the people we serve.

The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.

Company Profile Job:

At DentaQuest, we believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system – from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.

Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it. 

To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and delivering measurable outcomes for the people we serve.

The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.

Location_formattedLocationLong: Laguna Hills, California US

CountryEEOText_Description: In accordance with our Compliance Plan, employees must conduct business in accordance with applicable laws, regulations, professional standards and ethical standards and report potential compliance or ethical issues to manager or Compliance Officer. Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please see Human Resources for additional information regarding this Program. Equal Employment Opportunity Statement: We are committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, or sexual orientation.

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