The TPA Management and Network Evaluations role is responsible for the Stop Loss pricing related to PPO Networks and TPA capabilities. Additionally this role will be responsible for supporting the profitable growth in all administrator categories, monitoring of results, and identifying and implementing corrective actions as appropriate. This role will work withDistribution and Underwriting to identify, manage and capitalize on viable growth opportunities, TPA Solutions to assess TPA capabilities and develop value-add programs, among others.
- Provide oversight and direction to the Stop-Lossnetwork evaluationteam:
- Establish and maintain effective pricing models for evaluating traditional medical networks
- Identify, evaluate and monitor new medical network structures (ACOs, reference-based pricing, narrow networks)
- Leverage network partners to identify opportunities to support growth of stop-loss business
- Act as a subject matter expert related tonetwork offerings and TPA capabilities and theirassociated values to bothinternal partners and external partners.
- Serve as relationship manager to key network partners
- Proactively identify opportunities to share information with business partners through formal training sessions, internal documentation, etc.
- Drive creation of managementreporting to key stakeholders in Stop-Loss business related to TPAs andNetworks
- Identify and execute corrective actions as needed to manage TPA and network pricing
- Partner with Underwriting and Distribution to identify, support and grow profitable TPA relationships or fix unprofitable relationships.
- Enhance reporting to include complete view of profitability, incorporating related compensation expenses, recommending changes to compensation programs as appropriate
- Provide ongoing pricing assessments of administrators and their cost containment programs
- Identify new ways to assess impact of external / internal cost containment programs on catastrophic claims and develop a pricing strategy to appropriately reflect this impact in stop-loss manual rates
- Provide management and direction to one directreportsupporting theresponsibilitiesabove.
- Develop staff to proactively supportsales and underwriting teams
- FSA with 7+ years of proven healthcareactuarialexperience, stop-loss experience a plus
- Superior analytical, technical, and communication skills
- Ability to deal with imperfect data, and identify supplemental data sources
- Strong capability to deal with ambiguity
- Ability to work across different functional areas
- Prior experience with medical networks or provider contracting a plus
- Prior management experiencepreferred