Community Health Options

Role Description The Leader of Project Management Office (PMO) and Business Integration is a senior leader responsible for aligning the organization’s project portfolio with strategic goals, driving cross-functional execution, and ensuring the successful adoption of changes across the business. This role oversees complex, enterprise-wide initiatives, establishing governance, project methodologies, and reporting structures to maximize value and minimize project conflicts. - Enhancing the scope and capabilities of the department with dedicated resources focused on the integration of business needs and processes with technology. - Aligning vendor management activities with procurement and management of vendors to support Community Health Options’ ongoing business operations. Essential Functions and Responsibilities - Overall Strategy and Project Management: - Facilitates effective planning and approach with COO to guide the Executive Team to define annual objectives. - Translates strategic goals into actionable, prioritized project portfolios. - Defines and maintains the end-to-end enterprise initiative lifecycle (intake, scoping, planning, reporting, and closure). - Breaks down departmental silos to ensure initiatives are integrated across business units. - Provides visibility into portfolio health, including financial performance, capacity, and risk management to executive leadership. - Ensures that project outcomes are not just delivered but successfully adopted and sustained within the company culture. - Business Integration: - Leads dedicated resources to develop and deploy approaches for identifying and prioritizing inefficient processes. - Analyzes improvements and needed technical changes, deploys improvements, and monitors to validate objectives. - Establishes and drives ongoing support activities to translate complex business requirements into actionable system changes. - Vendor Management: - Designs and deploys robust tools and approaches for soliciting vendors ensuring business, technical, and compliance inputs. - Drives improvements in vendor adherence to contract terms, service level agreements, and financial obligations. - Establishes ongoing monitoring mechanisms to ensure oversight and transparency into performance. - Administers Corrective Action Plans (CAPs) and their reporting to Compliance Committee for overall monitoring. Job Specific Key Competencies (KSAs) - Strong ability to navigate ambiguity, influence senior stakeholders, and lead cross-functional teams. - Deep knowledge of project management frameworks (Waterfall, Agile, Hybrid) and project portfolio management (PPM) tools. - Demonstrated understanding of health plan administration, operations, clinical management, vendor management, and procurement. - Strong analytical capabilities including performance measurement, cost-benefit analysis, benchmarking, and process optimization. - Exceptional interpersonal, communication, and presentation skills. - Effective communicator with executive leadership, driving decisions with clarity of purpose. - Lead negotiator and pricing strategist for vendor management. - Data and metrics oriented leader in managing vendor performance. Qualifications - Bachelor's degree in Business, Technology, or a related field is required. - Certifications in Program Management Professional, Portfolio Management Professional, Six Sigma, or other relevant training. - 10+ years of Project Management and/or managing a PMO. - Extensive knowledge of the health insurance industry and insurance business processes. - Experience managing small and large teams and communicating at all levels within an organization. Diversity, Equity, and Inclusion Statement Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. - Respectful, open communication and cooperation between all employees. - Teamwork and participation, encouraging the representation of all groups and employee perspectives. - Balanced approach to work culture through flexible schedules to accommodate varying needs of our people. - Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

Role Description The Director, Provider & Network Operations is responsible for providing guidance and oversight over network management including: - Provider Relations - Provider Contracting - Credentialing - Provider Data Integrity The Director will exhibit insight, innovation, and leadership to drive multiple strategies while continuously improving quality, financial viability, access, and provider satisfaction. The position will assist in developing, leading, aligning, and implementing the execution of tactical initiatives and strategies. In partnership with the Senior Vice President, CFO, and Senior Leadership, the Director will integrate provider network plans, activities, and policies throughout the department to meet company objectives. The position is responsible for monitoring all aspects of the network, provider performance, and trends to ensure networks are developed and suitable to meet business needs. The Director will serve as a liaison between the organization, hospital leaders, and physicians to develop, communicate, and execute strategic direction for the network. This position will also be directly involved in contracting discussions with larger and more complex partner arrangements. Qualifications - Bachelor's degree is required; master's degree desirable - Minimum 5 years of management experience - A minimum of 5 years of experience in provider contracting and provider relations - Must understand Medicare, RBRVS, case rate, capitation, and other related payment structures Requirements - Responsible for assuring the financial viability, overall service, and quality and performance of provider networks - Oversees the development and implementation of provider contracting strategies and negotiations - Leads provider contracting and servicing activities for business expansion - Develops and implements strategies to strengthen and/or develop new physician, hospital, and other provider relations - Defines provider network expansion requirements in new and existing geographic service areas - Approves and monitors special requests, retroactive adjustments, reimbursement, and contract exceptions - Modifies networks, contracts, reimbursements, credentialing standards, and utilization trends as needed - Collaborates with physicians and other organizations to develop mutually beneficial business opportunities - Maintains access to a high-quality, geographically desirable, cost-effective network of specialists, hospitals, and ancillary providers - Directs the implementation of new health plan contracts/product lines - Directs rate analysis, scope assessment, and geographic coverage assessment - Oversees all primary IPA, Medical Group, and Hospital market research - Oversees initiatives to engage with local or regional Accountable Care Organizations (ACOs) - Monitors industry changes, trends, and events to identify opportunities for market penetration and performance improvement - Oversees recruitment of providers for new networks - Ensures network providers meet quality, cost, and coverage standards - Develops and manages team and corresponding budget - Provides strategic direction to lead network development - Assists with provider relations activities as needed - Collaborates with internal teams to align network strategy with clinical and financial objectives - Updates and interfaces with senior leadership team on initiatives - Oversees the determination and implementation of any health plan or regulatory corrective action plans Benefits - Superior customer service support is essential - Excellent organizational and time management skills Diversity, Equity, and Inclusion Statement Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces: - Respectful, open communication and cooperation between all employees - Teamwork and participation, encouraging the representation of all groups and employee perspectives - Balanced approach to work culture through flexible schedules - Employer and employee contributions to the communities we serve

• Responsible for assuring the financial viability, overall service, and quality and performance of provider networks. • Oversees the development and implementation of provider contracting strategies and provider contracting negotiations and ensures the terms of the contracts are fulfilled. • Leads provider contracting and servicing activities for business expansion. • Develops and implements strategies to strengthen and/or develop new physician, hospital, and other provider relations. • Defines provider network expansion requirements in new and existing geographic service areas, and for new lines of business. • Approves and monitors special requests, retroactive adjustments, reimbursement, and contract exceptions. • Modifies networks, their composition, contracts, reimbursements, credentialing standards and utilization trends as needed to assure goals are met. • Collaborates with physicians and other organizations to develop and pursue mutually beneficial business opportunities to meet community needs for health care services. • Maintains access to a high quality geographically desirable cost-effective network of specialists, hospitals, and ancillary providers to meet the needs of members served. • Directs the implementation of new health plan contracts/product lines which respect to the Provider Network Management responsibilities. • Directs rate analysis, scope assessment, and geographic coverage assessment prior to extending agreements to providers recruited to satisfy network needs. • Oversees all primary IPA, Medical Group and Hospital market research to gain qualitative and quantitative data to bring definition to market strategies. • Oversees initiatives to engage with local or regional Accountable Care Organizations (ACOs). • Monitors industry changes, trends, and events to proactively identify opportunities to increase market penetration and performance improvement. • Oversees recruitment of providers for new networks; optimizes size and composition of existing networks, and other projects necessary to meet business performance and growth goals. • Ensures network providers meet quality, cost, and coverage standards, and comply with applicable laws, regulations, and accreditation requirements. • Develops and manages team and corresponding budget as needed to assure success. • Provides strategic direction to lead network development to enable continued growth, profitability, and industry leadership. • Assists with provider relations activities as needed. • Collaborates with internal teams including medical management, operations, and risk adjustment to align the network strategy with clinical and financial objectives. • Update and interface with senior leadership team as appropriate on initiatives. • Ensure network providers meet quality, cost, and coverage standards, and comply with applicable laws, regulations, and accreditation requirements. • Oversees the determination and implementation of any health plan or regulatory corrective action plans related to provider network activities.

• Lead organizational quality improvement initiatives • Ensure compliance with accreditation and regulatory standards • Oversee quality data abstraction for NCQA HEDIS measures, CAHPS, and HOS surveys • Collaborate with internal stakeholders to close gaps and achieve performance targets • Coordinate accreditation readiness activities • Maintain knowledge of NCQA and URAC standards • Perform root cause analysis and implement corrective action plans • Analyze audit findings and develop corrective action plans