For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.Positions in this function are responsible for the successful program design, compliance with network requirements, network assessment and selection, and program/product implementation. This includes enterprise wide Clinically Integrated Network teams that focus on specific clinical area Lines of Service (e.g., Cardiology, Women's Health, Oncology, etc.) to improve the quality and affordability through improvements in appropriateness and effectiveness. May perform network analysis and strategy development and implementation. Obtains data, verifies validity of data, and analyzes data as required. Analyzes network availability and access. May make recommendations regarding use, expansion, selection of networks for various products based on that analysis.The Network Performance Specialist is responsible for provider performance management of select, high value, provider accounts. This is tracked by designated provider metrics, STAR gap closure and coding accuracy. The person in this role is expected to work both internally and externally with care providers to build relationships, ensure effective education and reporting, proactively identify performance improvement opportunities through analysis and discussion with subject matter experts; and influence provider behavior to achieve needed results. The person in this role will have a focus on claims and understanding the billing needs of select accounts.Primary Responsibilities:
Analyzes and investigates
Full range of provider relationships service interaction s including working end to end provider claim concerns, credentialing, rostering and ease of physician portal and future enhancements
Provides explanations and interpretations within area of expertise
Uses pertinent data and facts to identify and solve a range of problems within area of expertise
Investigates nonstandard requests and problems, with some assistance from others
Works exclusively within a specific knowledge area
Prioritizes and organizes own work to meet deadlines
Provides explanations and information to others on topics within area of expertise
Review employer group/health plan expectations (e.g., commercial; government) to determine the potential impact to employer group/health plan membership
Gather data from relevant sources to respond to stakeholders' requests (e.g., employer groups, internal teams)
Analyze network and/or provider performance along key indicators (e.g., compliance with regulatory audits, financial performance
Benefit Cost Ratio; risk adjustment scores; prevalence rates; Unit Cost Reduction Trend) to determine which programs to implement and/or modify
Research competitor and external information regarding key network characteristics and contracting strategies to develop products and programs
Ensure relevant contract and demographic information is loaded into the applicable platform to support analysis and review
Review and/or analyze member/provider population information (e.g., cultural information; demographics; geographic coverage) to determine potential network gaps in care and risk adjustment indicator opportunities
Implement new rates with contracted providers based on provider performance
Validate network data for programs (e.g., transparency program)
Develop metrics and create performance reports for pay-for-performance programs (e.g., PBC; PCPI)
Determine performance metrics and programs to apply to specific providers based on competitive data, internal data (e.g., provider improvement opportunities) and applicable legal and regulatory requirements
Provide guidance to internal stakeholders regarding administration of contracts (e.g., contract language; coding) and advocacy
Identify needs and create infrastructure and parameters for programs/networks/contracts (e.g., contract language; clinical quality initiatives; internal support)
Communicate with key stakeholders (e.g., UHN Leadership, Advocates, network management contractors) to ensure programs/networks/contracts comply with standards
Provide input and feedback to senior leadership to suggest/recommend improvements to programs/networks/contracts
Coordinate with relevant internal and/or external stakeholders to ensure that programs/networks/contracts are designed and implemented to meet local, regional, and/or national market needs
Work with Business Partners to create and/or implement communication/training materials (e.g., talking points; FAQs; step action chart; metric evaluation tools) to educate affected stakeholders on innovative programs and/or
processes. Program Managers may contribute to documents
Network Program manager may conduct interactions with external health care providers to promote risk adjustment score accuracy (e.g., early detection; accurate documentation and coding) and compliance with applicable regulatory guidelines (e.g., CMS; HEDIS/STARS Quality Measures)
Work with local, regional, and/or national networks and/or stakeholders in order build support for program/contract implementation
Seek feedback from relevant internal and/or external stakeholders regarding potential program/network improvement opportunities and needs
Conduct initiative-taking outreach with external stakeholders (e.g., health care providers; health plan) to demonstrate the value of services and offerings
Collaborate with relevant internal and/or external stakeholders to resolve issues and obstacles with network/program/contract performance
Collaborate with the contracting team to ensure adherence to internal contracting standards
Communicate with applicable stakeholders to provide performance updates regarding program/contract implementation (e.g., objectives; goals; timelines; schedules; issues; performance against standard contract agreements)
Follow up with stakeholders to ensure issues have been resolved and addressed effectively and timely
Manage external relationships with third party vendors to ensure program SLAs are met
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.Required Qualifications:
2+ years of clinical or managerial experience in Healthcare Operations OR 2+ years of claims experience OR 2+ years of experience within a managed care environment OR 2+ years of provider relations experience
Understanding of healthcare value-based concepts, payment methodology, and fee for service reimbursement methodologies across various specialties and facilities
Advanced knowledge of Microsoft PowerPoint; proficiency in Microsoft Excel and Word
Ability to travel 50% of the time in New Mexico
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
