Job Profile: Provider Network Director

Health insurance is a major industry valued at $748 billion that strives to keep medical care affordable for the public. Provider networks are groups of health delivery systems that have contracted with an HMO or PPO to provide insured treatment. Networks can include physicians, specialists, surgeons, medical labs, hospitals, home health services, hospices, nursing homes, psychologists, and more. Insurance companies create provider networks to ensure their members access quality care at a discount. Often, a provider network director is hired to direct the development of these networks for health insurance carriers. Provider network directors play a pivotal role in building relationships with various medical organizations. Directors will draft, review, negotiate, and finalize all contracts with all healthcare providers in the network.

Salary

Based on survey data from Salary.com, it’s estimated that the median yearly salary for provider network directors in the United States is $133,862. This equals a mean hourly wage of $64 or average weekly earnings of $2,574. When benefits, bonuses, pensions, and time off are included, provider network directors bring home an average total income of $210,136 each year.

Beginning Salary

Health insurance professionals just promoted to the role of provider network director typically land in the bottom 10th percentile of earnings, but still break the six-figure mark at around $105,485. However, provider network providers with years of experience often eventually make a base salary upwards of $161,120 annually.

Key Responsibilities

Provider network directors have the primary responsibility of leveraging insurance contracts with quality healthcare providers for optimal financial results. Directors will reach out to health delivery systems and evaluate their services based on company mandated criteria. They then develop a medical provider network by strategically negotiating contract constraints. Other daily duties for a provider network director could include ensuring compliance with contract guidelines, preparing financial projections, facilitating membership growth, overseeing insurance claims for accuracy, customizing fee schedules, attending task force meetings, and reporting to insurance company executives. Most will work in concert with a network manager and quality assurance manager.

Necessary Skills

Being a provider network director will require excellent interpersonal skills to effectively communicate all contractual processes. Writing skills are importance since provider network directors draft the contracts given to healthcare organizations. Having a knowledge of medical terminology is a must since directors review the network’s insurance claims process. Provider network directors must be detail-oriented with the organizational skills to prepare and record meticulous reports. Analytical skills are essential for provider network directors to correctly interpret complex contract regulations and policies. Directors should also have the negotiation abilities to only establish profitable working relationships with providers.

Degree and Education Requirements

At the minimum, provider network directors must be trained with four years of post-secondary education. Most directors have received a bachelor’s degree in health administration, business administration, finance, economics, accounting, or management. Taking coursework specifically related to the health insurance industry will be helpful. Due to job competition, it’s increasingly common for provider network directors to attend graduate school for a master’s. Obtaining a Master of Health Administration (MHA) or Healthcare MBA will develop the business acumen to effectively manage a healthcare provider network. In some cases, provider network directors are former licensed clinicians with an M.D. or D.O. degree.

Pros and Cons of the Position

Like any healthcare career, working as a provider network director will provide advantages and drawbacks you should be prepared for. On the plus side, provider network directors are granted a lucrative, senior-level administrative position with a six-figure salary and excellent benefits. Directors can find jobs in virtually any geographical area since health insurance companies are abundant. Provider network directors receive the intrinsic reward of helping their carrier make money while increasing patients’ access to quality, discounted care. However, provider network directors must invest in significant education. Travel could be required up to 25 percent of the time for visiting and meeting with healthcare providers. Provider network directors have a stressful job that requires more than the usual 40-hour workweek. Dealing with piles of contractual paperwork and balancing many figures can be overwhelming to some.

Getting Started

Having an impressive resume with plenty of experience in the health insurance industry is the only way to be promoted to provider network director. While in school, search for internships or administrative residencies that place you in medical insurance management. Most carriers require provider network directors to have at least five years of experience in provider servicing. It’s likely you’ll have to work your way up from health insurance specialist or claims adjuster into mid- and upper-level management. You’ll then become familiar with the concepts, practices, and procedures involved in healthcare provider networks. Pursuing professional certification can aid in your promotion. For instance, you could become a Certified Medical Insurance Specialist (CMIS) through the Practice Management Institute (PMI). Receiving the Management Liability Insurance Specialist (MLIS) credential could also be smart.

Future Outlook

The health insurance marketplace is booming thanks to the efforts of President Obama and the Affordable Care Act (ACA). In the past five years, over 16.4 million uninsured Americans gained health coverage. More and more people are being given the healthcare security they deserve through insurance, which means provider networks are expanding. Although the BLS doesn’t track data on provider network directors, the overall employment of health services managers is projected to grow by 17 percent through 2024. Jobs will be fiercely competitive due to their small numbers though. Provider network directors with a master’s degree and knowledge of healthcare IT systems will fare the best. Some of the largest health insurance companies include Aetna, Kaiser Permanente, UnitedHealth, Humana, and Blue Cross Blue Shield.

Overall, provider network directors are given the hefty task of developing a stable, broad access network for an insurance company’s customers to receive affordable care. Directors must anticipate customer needs and proactively establish network solutions to fulfill them. Provider network directors build strong business relationships with hospitals, physicians, pharmacies, surgical centers, and other ancillary providers. If you work towards becoming a provider network director, you’ll have the unique opportunity to use your clinical knowledge for maintaining a cooperative provider community that meets every patient’s unique medical needs at a fair price.

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