Description: Collaborates with regional health plan and medical group executives to lead and negotiate cost-effective, quality-oriented contracts for hospital, ancillary, and non-MD/DO services. Responsible for leading all network provider relationships as it relates to Health Plan operations. Negotiates purchase of hospital and ancillary based services. Accountable for hospital/ancillary network development and management & financial performance to achieve regional business goals. Oversees and strategizes budgeting and forecasting for community medicals services and ARM/DME. Develops and builds relationships with statewide and mainland provider contracts and physician contracts. Leads and manages negotiations. Achieves favorable contract terms. Identifies outside and inside service needs and opportunities to complement overall care delivery. Coordinates provider contracting activities in conjunction with strategic goals, business and marketing plans. Directs provider relation activities to meet needs of contracted providers. Guides analysis activities to meet needs of internal staff. Collaborates with appropriate leadership teams with development of joint ventures and purchase strategies. Develops and maintains relationships with external and internal care providers. Procures medical care/service contracts to meet regional cost requirements and quality of care standards. Oversees quality activities specific to affiliated care practitioners. Ensures consistent member benefit applications across ARM & DME. Serves as role model. Supervises assigned staff.
- Ability to analyze, evaluate, articulate strategic issues & solutions. Analytical skills, to evaluate & fully understand financial models for negotiations & be a sharp thinker during financial negotiations.
- Budgets and forecasts outside service needs of organization. Oversees and strategizes budget.
- Have a solid understanding & experience to recognize the End-to-End aspects of the Provider Contracting involving Claims, configuration, UM, contract modeling and analytics, etc.
- Lead and manage negotiations to achieve favorable contract terms. Have authority to design and implement negotiated agreements and manages internal approval of agreements reviewed at the Hospital Contracting and Strategy Committee.
- Builds & maintains collaborative relationships w/ hospital & system executives as well as medical group & health plan leadership including but not limited to claims, UM, sales & marketing, actuarial, quality, operations & finance to ensure successful implementation of initiatives.
- Identifies and/or anticipates outside and inside service needs to complement overall care delivery. Collaborates with appropriate leadership teams in budgeting, forecasting, and development of purchase strategies and other objectives. Procures medical care/service contracts for health plan membership to meet regional cost requirements and established quality of care and service standards. Monitors compliance with contract terms and conditions. Negotiates disputes.
- Develops and maintains relationships with external and internal care providers. Represents organization at external meetings. Directs provider relations activities to meet needs of contracted providers. Performs other provider relations activities.
- Leads the provider contracting and analytic management team who oversee the day to day operational activities of the provider contracting and analytic staff.
- Assists in the development of hospital and ancillary contracting, network management & provider relations capabilities within KPHI; developing policies & procedures & best practices to ensure that contracting processessupport the HI region's business goals.
- Provides day-to-day management of provider relations and contracting activities for affiliated care contract implementation and administration. Manages a multidisciplinary contracting and reimbursement team. Coordinates with HPMG Provider Relations Staff to ensure alignment. Establishes work priorities. Plans, coordinates, and schedules workloads. Ensures compliance with related regulatory requirements, Provides counsel to regional leadership and work teams on contracting issues. Drafts and interprets legal documents, with assistance from other departments as necessary.
- Directs qualitative and quantitative analysis of contracts for impact assessment. Oversees financial analysis of contract effectiveness. Formulates short- and long-term strategies to minimize outside service cost while providing high quality. Recommends changes as appropriate. Participates in development of industry, competitor, and internal analyses used by leadership teams to formulate cost-reduction, allocation and rate-setting strategies.
- Oversees HDO credentialing process. Ensures maintenance of current licenses and certifications. Establishes and maintains relationship with professional competency to facilitate LIP credentialing.
- Manages payroll and/or non-payrollbudget. Monitors expenditures. Ensures compliance with budget. Promotes effective use of resources.
- Monitors external health care delivery marketplace and internal utilization trends. Maintains a contracting strategy that is cognizant of current market trends, and aligns incentives among providers within the delivery system. Assesses new opportunities for cost savings, alternative delivery models and financialrisk sharing.
- Works collaboratively with the Medical Group in developing & communicating negotiation strategies & tactical approaches, including value based contracting outcomes.
- Identifies & implements strategies for improvement of the medical loss ratio through the enhancement of external medical cost analytics.
- In addition to defined technical requirements, accountable for consistently demonstrating service behaviors & principles defined by the KP Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives.
- May perform patient care to the extent necessary to maintain clinical expertise, competency, and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.
- Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed.
- Incorporates the KP Nursing Vision, Model and Values throughout their Nursing Practice.
- Minimum five (5) years of management experience.
- Minimum ten (10) years of contracting and contract negotiations experience to include medical expense and utilization analysis Education
- Master's degree in business, finance, or health care administration or six (6) years of experience in a directly related field required. License, Certification, Registration
- Valid driver's license.