Set and implement successful, innovative Network Strategy including but not limited to creative contracting collaborations (Shared Savings to Full Risk, ASO, PCMH, bundled contracting). Build and mentor internal team structure to support provider contracting and relations. Create and drive market innovation in achieving triple aim, reduction in healthcare cost, improvement in quality outcomes, and access to care. Champion for strong and effective foundational relationships across the enterprise. Pivotal role to activate, engage and impact the performance of the business. Strengthen cross segment capabilities across enterprise.
Accountabilities that Support the Strategic Outcomes:
- Develops and executes on Network Strategy inclusive of reimbursement methods, pay for performance, provider collaboration agreements, network "tiering", and ACO and PCMH type arrangements. Evaluate effectiveness of incentive arrangements and course correct when needed.
- Works directly with CMO and other VPs to drives the strategic direction and innovation agenda to reduce costs while prompting accountability to improving quality health outcomes.
- Cultivates relationships with key provider group practices and hospitals as lead negotiator in high impact settings.
- Directs and manages all aspects of Network Operations including internal budget controls, credentialing, provider relations, disputes, negotiations and contracting efforts.
- Collaborates with cross segment units to evaluate workflow process improvement opportunities for streamlining or creating efficiencies in provider payment- internal as well as external.
- Drives to raise the bar in outcomes by partnering and developing the skills in provider collaboration. Cultivates cooperative relationships with their respective organizations through leadership of key provider partnerships, designed to improve the quality and cost-effectiveness of care delivered to members. May share in chairing selected Committee.
- Refines and applies credentialing policy in accordance with NCQA standards. Reviews all credentialing and re-credentialing applications for network providers and facilities, and makes recommendations (in partnership with CMO) to the QIC for those requiring further review.
- Works in partnership with Analytics and reporting to set standards for Provider Collaboration expectation on thresholds as well as formal report sharing process for measuring success to plan.
- Cultivates relationships with community and governmental leaders
- Partnership with Product innovation and planning teams to present and drive cutting edge market vision ideas to maintain market leader position
- Oversees and manages to network access standards as well as drive network management levels based on service coverage and quality measures
- Develops and manages contracting process for all physicians, hospital, ancillary services. Establishes and administers requisite and compliance oversight, measurement and control processes to ensure attainment of unit cost objectives and compliance with contracting policies and regulatory requirements.
- Serves as support for regulatory compliance with HEDIS/STARS data interpretation, participating
- Performs other related projects and duties as assigned.
Technical Knowledge and Experience:
- Minimum 10 years of progressive and relevant business experience in health care industry with focus on contracting and network optimization.
- Strong communication skills both verbally and written, ability to prioritize issues and execute plan to problem resolution
- Experience in contract negotiations, preferable with experience in payer and provider organizations leading complex hospital, physician and ancillary contract negotiations- including evolving reimbursement models and methodologies, ACOs, PCMHs, Pay for Performance (P4P).
- Direct negotiation experience with risk contracts with strong financial acumen and a comprehensive understanding of contractual options, healthcare economics and competitor's practices.
- Demonstrated exemplary management experience in leading and directing data to day operations of multidisciplinary teams; credentialing, provider relations/training, claims/coding, and contract negotiations
- Deep knowledge of health plan operations, as it relates to medical cost and delivery of high quality care
- Extensive knowledge of health care industry, provider service operations, claims and relevant regulatory issues.
- Proven experience interpreting and utilizing competitive intelligence, financial analysis, contracting modeling and contract standards in development of contracting strategies
- Experience with Commercial, Exchange and Medicare-risk programs
- Experience with the management of IPA, PHO and/or group practice models related to medical utilization, and/or resource management and quality assurance.
- Computer literacy (Microsoft Word, Excel, PowerPoint, and Access) desirable as it relates to the ability to manipulate and analyze data.