C2Q Health Solutions

Compensation

Full Description

JOB PURPOSE: Under the direction and guidance of the AVP, Network and Vendor Contracting, the Director of Provider Relations provides hands-on leadership in the development, contracting, and management of the provider network. This role supports day-to-day provider relations operations while driving strategic network initiatives to ensure adequacy, regulatory compliance, and strong provider partnerships aligned with enterprise objectives and Department of Health (DOH) and Centers for Medicare & Medicaid Services (CMS) requirements. The Director is responsible for the development, negotiation, and ongoing management of provider contracts and for fostering collaborative, high-performing relationships across a diverse provider network. This includes working directly with IPAs, primary care and specialty practices, large medical groups, FQHCs, ancillary providers, home care agencies, hospital systems, and other provider organizations. The Director serves as the primary point of contact for provider-related inquiries regarding contract terms, set-up, billing, payment methodologies, and operational processes. This role ensures compliance with contractual, regulatory, and organizational standards while optimizing reimbursement structures and supporting network growth and performance. In collaboration and coordination with Business Development leadership, the Director is responsible for managing and maintaining relationships with the organization’s providers, including conducting in-person meetings and attending marketing/ business development events on behalf of the organization. The Director works directly with other internal stakeholders, i.e. clinical operations, claims, compliance, and finance to monitor provider performance, ensure quality outcomes of the organization’s members. JOB RESPONSIBILITIES: Under the direction and guidance of the AVP of Network and Provider Contracting, lead and actively manage provider network development and contracting initiatives to support seamless onboarding, enrollment, and network growth. Directly oversee and participate in the end-to-end provider contracting and onboarding process, including rate configuration, system set-up, data loads, and quality assurance. Develop, negotiate, execute, and manage provider contracts (and Single Case Agreements) across a diverse network, including IPAs, primary care and specialty practices, LHCSAs, FQHCs, ancillary providers, hospital systems, and other provider organizations. Maintain oversight of the full contract lifecycle, ensuring accurate documentation, timely renewals, amendments, and execution within the contract management system. Work closely with Credentialing team to ensure timely and accurate credentialing deadlines and documentation for each provider to maintain the organization’s network adequacy. Serve as a subject matter expert for provider-related issues, conducting research and coordinating internal and external resources to resolve matters efficiently and with urgency. Perform direct outreach to providers for escalation of critical issues that need to be addressed timely. Address and resolve provider concerns promptly, delivering responsive, high-quality customer service related to contracts, operations, and reimbursement. Escalate any critical issues to the attention of the AVP and CFO. Work closely with Finance and Claims Operations in provider outreach and education related to claim appeals, over/under capitation and claims recoupment, and Nokomis and DRG Claims denial process. In collaboration with Marketing team, conduct LHCSA and SADC annual training, issue Quarterly Provider Newsletter, update Provider Manual and Provider Portal contents, and other provider related notifications. Provide support to Shared Services and Care Delivery teams in the collection of Nursing Home notes and provider escalation for other visit notes. Perform site visits to SADC sites new to the organization’s network. Develop staff in ensuring the adherence to administrative policies, procedures, that leads to process improvements to enhance operational efficiency, compliance, and innovation. Ensure provider network compliance with Medicare, Medicaid, PACE, OMIG, NYSOFA, HIPAA, and other federal and state regulatory requirements in collaboration with Credentialing, Compliance, and internal stakeholders. Respond to and close out Corrective Action Plans (CAPs) and internal or external audit inquiries, including those from CMS and NY DOH, ensuring timely and accurate submission of requested information across all legal entities. Monitor and manage provider communications, including timely response to provider relations inbox inquiries, portal access issues, and coordination with appropriate internal teams. Support compliance and operational initiatives such as LHCSA wage parity (LS300), provider training materials, and IRS 1099 name/TIN resolution. In coordination with Business Development team, represent the organization in external meetings, conferences, and community events as needed. Lead special projects and initiatives as assigned while upholding organizational policies, confidentiality standards, and productivity expectations. Assume accountability for assigned responsibilities, seek guidance when appropriate, and consistently meet performance and operational goals Keep AVP of Network and Vendor contracting informed of progress, risk, and outcomes timely and close the loop on any follow-up discussions. All other duties assigned Management Standards Policies and Procedures: (1) Create Policies and Procedures needed, (2) Monitor Compliance, (3) Ensure all employees are aware of the policies, (4) Review them annually, (5) Discuss and obtain final approval of new or revised policies with the P&P committee annually. Responsible for overseeing the day-to-day operations of multiple departments. Your role is crucial in ensuring efficiency, maintaining quality, and upholding regulatory standards and KPIs. Conduct regular risk assessments to identify areas of potential non-compliance and vulnerability within the organization, developing strategies and controls to mitigate risks and strengthen compliance efforts. Anticipate industry trends and implement best practices and process improvements to enhance operational effectiveness and streamline workflows. Identify cost-saving opportunities and revenue enhancement strategies to optimize financial performance. Cultivate strong relationships with key stakeholders, including clients, partners, regulators, and community organizations. Clearly communicate performance expectations to all employees, including goals, objectives, and key performance indicators (KPIs), ensuring alignment with the organization's strategic objectives and values. Provide timely and constructive feedback to any employee under your organizational structure (Employees and Management at any level) regarding their performance, highlighting strengths, areas for improvement, and opportunities for growth. Address performance issues promptly to prevent them from escalating, maintaining accurate and comprehensive documentation. Promote a high-performance and continuous improvement culture that values learning and a commitment to quality. Schedule: 8:30AM – 5:30PM Weekly Hours: 40 QUALIFICATIONS: Education: Bachelor’s Degree in Business, Healthcare Administration, or other related fields. Masters’ candidates encouraged to apply. Experience: Two to five (2-5) years of experience working in healthcare preferably in managed care contracting, provider relations, or network development. Familiarity with physician onboarding, ancillary providers, and VBP arrangements. Other: Advanced computer skills including MS Office (Excel, Outlook, Word, etc.) and Adobe Acrobat. Highly organized, accountable, and detail-oriented. Customer service orientation with excellent follow-up and communication skills. Able to multitask efficiently and effectively as part of a team and independently. Solid critical thinking and problem-solving skills in a fast-paced, dynamic environment. Professional, friendly, and skilled in written communications. Physical Requirements Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to: Standing – Duration of up to 6 hours a day. Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods. Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc. Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job. Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas. Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.) Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy. Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual. Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job. Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company. We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. Salary Range (Min-Max): $138,000.00 - $145,000.00 C2Q Health Solutions offers management services tailored to the needs and goals of healthcare providers. Drawing from our leadership team's experience in providing key administrative solutions to healthcare programs such as managed long-term care, home care companies and other community health plans, C2Q’s expertise spans a full spectrum of functions that support an organization’s growth.