Summary
Lead provider innovation, initiatives and network strategies including network provider pricing/fee schedules, cost optimization, trend analysis, Provider Network improvement opportunities, value-based contracting, provider incentive programs and other strategies while continuously improving quality, access and customer satisfaction; exhibiting insight, innovation and leadership.
Maintain accountability for specific medical cost initiatives with an emphasis on executing productive provider contracts.
Serve as liaison between the organization, hospital physician, IPA and ancillary leaders to develop, communicate, and execute strategic direction.
Build relationships with internal senior stakeholders to align objectives, develop strategy, and maximize outcomes; work cross-functionally to integrate Provider Network plans, activities and policies throughout the enterprise to meet corporate objectives.
Direct and supervise Network staff in operations and relationship management associated with Enterprise goals
Develop and implement Provider Network innovation and optimization standards and guidelines to increase market share, revenue growth, and quality outcomes.
Responsibilities:
Contract Management:
Lead strategic provider relationships which includes negotiating, implementing and maintaining some of the most competitive and complex contracts with large health systems, hospital partners, physicians, IPA, ancillary providers and other provider entities.
Oversee staff that has day to day responsibility for managing the relationships that supports the EmblemHealth Provider Network, serving as escalation point for internal staff and external contacts regarding resolution of highly complex or unusual business problems that affect major contract functions, performance or relationships.
Meet regularly with providers at Joint Oversight Committee meetings to address all financial, operational, quality and contractual issues.
Participate in workgroups in which the Provider Network department is a stakeholder.
Financial Reporting:
Maintain Provider Support reserves for all contracts managed.
Attend routine Finance/Actuary meetings and report Provider Network updates.
Develop executive financial dashboards and reports reflecting underpayment and overpayment activities and payment trends.
Lead the provider settlement process.
Department Policy/Workflow Development, Training, and Implementation:
Work within the guidelines outlined in the Provider Network Contracting End to End process (planning, negotiation, and implementation phases) to develop contracting strategies, evaluate the current performance of contracts, assist in forming the model to evaluate and proposals or counter proposals received or sent to hospitals, facilities and any type of providers; evaluate impact of reimbursement rates and/or methodologies.
Implement strategies to achieve financial targets.
Develop and implement policies, procedures, and workflows for Provider Network department and all types of providers.
Identify training needs within the Department and external providers; coordinating training and developing materials to support same.
Staff development and training as needed to maintain efficient operations and growth.
Strategic Projects:
Responsible for implementation of HCCI or other Provider Network projects as assigned by leadership.
Manage strategic positioning for provider contracting, identifying and acting upon opportunities for greater value-orientation and/or other business/network development opportunities.
Stay attuned to industry and market trends and research on best practices and initiatives in developing new and innovative payment and network models that support quality-driven health care.
Network Compliance:
Ensure Provider Network contract compliance with all Plan and regulatory requirements.
Ensure timely responses to regulatory agencies (i.e. NYSDOH, DFS) in response to all Provider Network regulatory and compliance inquiries.
Qualifications:
Bachelor's degree in Health or Business Administration or a related field required
Master's degree preferred (MBA, MPH, MA)
10+ years' experience in the health care industry with increasing responsibility including staff management (R)
10+ years prior experience (contracting, provider and/or vendor management) (R)
Staff management experience preferred (P)
Familiarity with provider community and health care marketplace trends and superior knowledge of NYS hospital reimbursement and managed care laws and regulations. (R)
Network management, provider/facility service and contracting experience (R)
Strong quantitative skills including the ability to identify trends, analyze and interpret financial and utilization data (R)
Outstanding oral and written communication skills (R)
History of demonstrating initiative and out-of-the-box thinking along with the flexibility to implement change quickly (R)
Additional Information
Requisition ID: 220OI
