Sr. Network Program Manager, DentaQuest

The opportunity:  

This position is a strategic, cross-functional leadership role responsible for guiding the integration and implementation of provider networks. The role will collaborate on new business implementations and product integrations, ensuring provider networks are properly aligned and reimbursement models are accurately configured and implemented to meet both state and federal requirements. Responsibilities include, but are not limited to, developing provider contracts and amendments with legal, overseeing, and documenting policies related to the network, and partnering closely with compliance to ensure all regulatory requirements are met.

**Candidate must reside in the state of California.

How you will contribute:  

• Network strategy for network migration to WW.  Includes defining provider networks, defining individual provider participation in various networks, defining payment/reimbursement model of providers in various networks, ensuring outcomes align. 

• Work collaboratively with Ops and Config leaders on defining the network strategy to ensure operational build and outcomes align with products. 

• Lead development of provider agreements and amendments with legal specifically for provider contract agreement and/or amendment in all dental lines of business, and to align to future provider agreement updates and/or fee structure changes are reflected in all necessary contractual documents.

• Lead in partnership with Compliance the development of provider agreement storage and maintenance of all provider agreements into Compliance 360

• Lead with Compliance all provider network policy development and updates to meet all state regulations, contract requirements for government and commercial dental plans. Lead communications with network leaders on mandates and changes as applicable to provider network.

• Lead development of provider reimbursement models (standard payment, special deal payment, Prop56 and CalAim for government programs, capitation, other incentives) to ensure alignment with benefit programs, profitability, quality of providers for our company and the clients.

• Provide oversight of the implementation of provider reimbursement models in systems to ensure provider records and claim outcomes meet provider contract requirements.

• Lead network implementation on network reporting required metrics.  Work in partnership with Provider Intelligence leaders to ensure organization meets monthly, quarterly, annual network reports.  Provide leadership insight on development of provider quality monitoring and performance reporting, including provider performance reports and scorecards.

• Partner with organization leaders on network implementation for auth process, referral process, COC, portal development, and provider directory verification process aligns to contract requirement and provider expectations.

• Oversight and development responsibility of Provider Office Reference Manuals and EOCs to ensure policies and training align to ORM.  Working in partnership with Ops, clinical and CE leaders on benefit alignment to ensure all ORM updates from base template align to client contracts and policies.

• Provide leadership and collaboration with internal teams to assess provider network adequacy, access, and capacity while identifying areas for improvement.

• Provide strategic guidance on network development and network optimization, identifying high-performing providers and supporting contract negotiations as needed.

 What you will bring with you:  

• Bachelor’s degree or equivalent experience required.

• 10 years related experience.

• Strong interpersonal skills.

• Knowledge of Dental terminology and processes.

• Ability to be externally client and provider facing.

• Ability to effectively train and educate other team members (SME).

• Ability to handle multiple project and multiple priorities and be flexible.

• Excellent oral and written communication skills, professional demeanor.

• Analytical experience with provider network data and reporting.

• Report development experience.

• Ability to use good judgment and make quick independent decisions.

• Cooperative, professional, and effective interaction skills with leaders, co-workers and clients.

Salary: