Coordinate, negotiate and handle activities of the provider contracting function and aid in formulating and administering organizational policies and procedures. Negotiate hospital, physician groups and ancillary service agreements and oversee external customer service for providers in accordance with Health Plan and government regulations and guidelines.
Essential Duties and Responsibilities
- Typically provides leadership to managers and /or higher - level professional staff
- Typical span of control: Administrative 5-8, Clinical 6-8, Support Services 6-8; e.g. Admin: Fin, IT, Legal, HR, Public Affairs
- Typically accountable for the performance and results of multiple teams performing related activities
- Develops long-term plans and strategies for area of defined responsibility aligned with established functional strategies, and works with subordinate managers to operationalize and execute the strategy
- Communicates priorities and expectations, monitors progress, and provides direction and course corrections along the way
- Makes decisions guided by resource availability and functional objectives that affect the results of the function
- Analyzes key trends and input from individuals in the team to make meaningful changes that directly and significantly affect short-term results
- Establishes budgets and holds subordinate managers accountable for managing to achieve expected financial results
- Works on cross functional teams to develop and implement solutions that have a broad impact on the organization's operations and processes
- Lead provider contracting and relations activities to ensure efficiency and maintain compliance with Health Plan policies and standards, government laws and regulations.
- Effectively negotiate contracts with hospitals, physician groups and ancillary providers to support Health Plan financial and access goals.
- Develop and implement a network development plan for the assigned region and set of providers, and identify and initiate contacts with potential providers in support of the Health Plan's strategic goals and objectives.
- Effectively integrate new programs and strategies to reach per member per month targets, and provide oversight to the provider set-up and contract configuration in the computer system to ensure accurate claims adjudication.
- Perform basic financial analysis to identify medical cost improvement opportunities, develop strategies to reach financial goals, and execute contracting strategies to meet goals and objectives.
- Develop financial modeling tools as necessary.
- Evaluate and monitor providers' performance standards and financial performance of contracts and implement creative solutions for under performing contracts.
- Develop staff skills and competencies through training and experience.
- Establish and maintain strong business relationships with network providers.
- Maintain an expert level knowledge of Medicaid reimbursement methodologies.
- Four-year Bachelor's degree or equivalent experience preferred.
Licenses & certifications
- Four-year Bachelor's degree or equivalent experience required.
- 5-7 years of related experience negotiating hospital, large physician groups and ancillary service agreements and external customer service for providers. Experience in claims processing, marketing/sales, medical economics in a managed care or insurance environment preferred.
- Proven experience with diverse payment structures, such as experience in Medicaid and CHIP reimbursement experience, capitation, DRG, case rates, carve outs and other risk preferred.
Specific knowledge, skills, and abilities
- Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
- Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
- Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
- Vividly communicate a compelling view of the future state in a way that helps others understand and feel how business outcomes will be different when the vision and values become a reality.
- Demonstrate a poised, credible, and confident demeanor that reassures others and commands respect; convey and image that is consistent with the organization's vision and values.
- Clearly and succinctly convey information and ideas to individuals and groups; communicate in a focused and compelling way that captures and holds others' attention.
- Light - Exerting up to 20 lbs. occasionally, 10 lbs. frequently, or negligible amounts constantly and may require walking or standing to a significant degree.
Location: Dallas, Texas
Activation Date: Tuesday, November 19, 2013
Expiration Date: Tuesday, April 1, 2014