Resp & Qualifications

PURPOSE: 
This position is responsible for the planning and managing of day-to-day Dental network operations, activities and compliance matters regarding existing networks and additional future networks. This position is responsible for preparation of CareFirst's entry into new markets, network expansion and ongoing development, maintenance and oversight, ensuring the contracting strategy development and ensuring competitive network access for CareFirst members that meets all jurisdictional and contractual requirements. 

ESSENTIAL FUNCTIONS:
Manage, plan and organize departmental functions associated with the development and maintenance of current and other future Dental networks. This involves, but not limited to, the following accountabilities: 

• Establish and maintain strong collaboration with Sales, Marketing, Actuarial, Government Programs, Legal, Practice and Payment Transformation, Health Services, and other departments as needed for development of new networks, including but not limited to development of contracting strategies. 
• Responsible for competitive network access (balancing cost, quality, and access) for current and future networks, including but not limited to development of contracting strategies. 
• Work with appropriate teams for consistent monitoring and ongoing maintenance and ensure continued network access in accordance with MIA, NCQA and other access requirements. 
• Develop processes, procedures, and policies in coordination with Embedded Compliance team. Ensure staff is trained and adheres to policies and procedures.  Prepare and submit monthly performance metrics as needed. 
• Remains alert and inform to industry trends and held accountable and credible in the eyes of internal and external customers to be an expert in the area.
• Leads strategy, negotiation and oversight of complex health system and provider negotiations  in coordination with Provider Contracting and Recruitment. Develops and maintains processes for the coordination, collaboration, and hand-off to Provider Contracting for the contracting of selected providers based on quality, cost, provider scorecard and other factors as appropriate for the development of each new network.
• Chairs and/or represents Networks Management on external and internal committees (and departments) to support programs, corporate initiatives, legislative requirements and system initiatives.

SUPERVISORY RESPONSIBILITY:
Leads a team utilizing a matrix management system.

QUALIFICATIONS: 

Education Level: Bachelor's Degree in Business, Healthcare, Finance or related field or equivalent experience, with strong financial background OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience:

• 5 years healthcare insurance industry with specific experience in contracting, negotiation and reimbursement development.
• 3 years commercial and/or government programs network experience.

Preferred Qualifications:

• Analytical skills principles as evidenced by CPA or MBA highly desirable.
• Knowledge of CareFirst's or other payer's provider networks and contracts.

Knowledge, Skills and Abilities (KSAs) 

• Computer software applications.
• Effective team leading skills to plan, direct, and monitor department activities to ensure the achievement of corporate and divisional goals. 
• Extensive knowledge of the healthcare industry, legal/regulatory issues and operations knowledge, including thorough knowledge of provider reimbursement methodologies and claims processing guidelines. 
• Strong interpersonal skills to effectively represent Networks Management within the organization and represent CareFirst interest to the provider community. 
• Effective human relation skills to direct, lead, and motivate team members towards goal attainment. 
• Strong analytical skills are needed to evaluate financial arrangements and negotiate cost effective terms.
• Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as the ability to understand and interpret complex information from others.  Proficient in speaking in both individual and group settings, particularly with providers and internal staff. 
• Ability to multi-task, shifting back and forth effectively among multiple activities. 
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
  
  

Salary Range: $83,952 - $166,738 (salaries are based on education, years of experience & internal equity)

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