Director Commercial Provider Contract

Description

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JOB SUMMARY

This position works within a matrixed environment to create the organization’s assigned business network strategy (government, commercial, etc.). Leads all aspects of provider network strategy including, but not limited to: discounts analysis, competitive analysis, access analysis, network operations, cost savings initiatives and Pay for Value (P4V) initiatives. Supports executive decision makers with analysis related to reimbursement and unit cost management. Oversees the entire business contracting paradigm, including coordination with various departments as well as leading the negotiation for the contracting team. Establishes a provider recruitment plans for expansion, new product support and overall network re-contracting.

Accountable for monitoring recruitment to ensure compliance with program contractual network adequacy standards and coordinates with other departments to ensure the provider network meets the healthcare needs of plan members. Oversees development of provider contracts to ensure compliance with state specific requirements.

ESSENTIAL RESPONSIBILITIES

• Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
• Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
• Creates the assigned business network strategy relative to network access. Ensures that equitable rates are negotiated for all providers and that provider agreements are in place that appropriately reflect the relationship. Works to ensure that all healthcare costs control mechanisms are fully implemented and executed.
• Provides input and leadership for the design and implementation of strategic reimbursement related activities. Collaborates with other network development staff and external consultants in the development of provider networks across expansion markets. Performs periodic analyses of the provider network from a cost, coverage, and growth perspective. Provides valuable input into evaluating opportunities to expand or change the network to meet the business’ goals and objectives.
• Performs analysis of claim trend data and/or market information to derive conclusions to support contract negotiations. Conducts periodic review of provider contracting rates to ensure strategic focus is on target with organizational strategy.
• Support market expansion and program activities by leading provider contract analysis and network development related to due diligence.
• Other duties as assigned or requested.

REQUIRED EDUCATION

• Bachelor's Degree - Business Administration, Healthcare Administration or related field or relevant experience and/or education as determined by the company in lieu of bachelor's degree

PREFERRED EDUCATION

• Master’s Degree - Business Administration, Healthcare Administration or related field

EXPERIENCE

• 7 - 10 years' experience in managed care network development and provider relations/contracting management in a healthcare and/or managed care environment
• 7 - 10 years' experience in healthcare administration/financing/delivery or a related field
• 5 - 7 years' of increasingly responsible management positions
• Prior experience negotiating large scale provide contracts

KNOWLEDGE, SKILLS & ABILITIES

• Complete understanding of all reimbursement methodologies used across the healthcare continuum (ex. % of charge, DRG, APC)
• Ability to effectively communicate and negotiate with C-suite level representatives of hospitals and health systems
• Critical thinking
• Decision making

REQUIRED LICENSURE

None

PREFERRED LICENSURE

None

TRAVEL REQUIREMENT:
50% - 75%

LANGUAGE REQUIREMENT ()?
None

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
Office-Based

An employee in this position works in an office environment. The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email). The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks. The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.

Teaches/Trains others regularly

Occasionally

Travels regularly from the office to various work sites or from site-to-site

Frequently

Physical Work Site Required

No

ADDITIONAL INFORMATION

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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