Reporting to VP of Network, the Director, Contracting and Network Management is responsible for leading the development and execution of contracting strategies for assigned geographies and health delivery networks. Working closely with the regional executive teams, s/he will lead the market's contracting activity that secures a quality, cost-effective provider network of healthcare services consistent with corporate guidelines and requirements.
General Duties/Responsibilities:
(May include but are not limited to)
Identifies, evaluates and executes contracting and network development strategies in established and new markets.
In conformance with corporate standards, including network adequacy requirements and performance targets, negotiates, implements, and manages capitated and fee-for-service agreements with individually contracted Primary Care Physicians (PCP), medical groups, hospitals, integrated delivery systems, ancillary providers and specialists.
Analyzes current and projected network needs from cost/utilization and competitor standpoints for decision making purposes.
Negotiates all compensation methodologies including but not limited to capitation, per diems, case rates and incentive programs. Develops new reimbursement models in concert with leadership.
Conducts contract modeling and analysis in coordination with Finance.
Analyzes, negotiates, and drafts contract rate and language proposals consistent with corporate guidelines for language, financial and operational performance.
Oversees administration of the contracts to ensure anticipated results, identify negative performance trends, and implement cost containment and other improvement strategies.
Works closely with VP of Network, Regional Medical Officers, Market President and other departments to ensure overall success of the market.
Collaborate with regional executive team and other departments to ensure contracted network support of operating goals, including STARS, HEDIS, RAF, and other initiatives.
Participates in monthly market review meetings with regional and corporate leaders.
Develops strong relationships with key provider stakeholders.
Oversees the maintenance of all contract templates to ensure contract compliance with regulatory requirements and established policies and procedures.
Oversees assigned staff; recruits, develops and manages performance.
Recommends and establishes department metrics. Sets goals for staff and the market.
Contributes expertise to development of organizational best practices.
Supervisory Responsibilities:
Oversees assigned staff. Responsibilities include: recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; coaching, counseling, and disciplining employees.
Minimum Requirements:
Minimum Experience:
10 years of experience in managed care or health care field, including a strong understanding of reimbursement methodologies, contract language, negotiation strategies, financial modeling and analysis, managed care and Medicare Advantage plans; or any combination of education and experience, which would provide an equivalent background.
Education/Licensure:
Requires a BA/BS; MBA strongly preferred.
Other:
Strong knowledge of Medicare managed care.
IPA experience preferred.
Proficient with contractual provisions and structure for specific provider type (e.g. hospital, ancillary, physician)
Network relationship knowledge and skills.
Must have strong analytical skills
Excellent executive interpersonal and relationship management skills
Strong management skills.
Excellent oral, written and presentation skills
Proven ability to foster collaboration, value others perspective and gain support and buy-in for organization proposal.
Excellent Microsoft Office skills, including Word and Excel
Experience with delegated and non-delegated providers
Ability to travel by car or air
Available for evenings/weekends and extended work hours as needed
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
