Senior Director of Provider Contracting

Job Description

Job Description

Position Overview :

MetroPlus Health  is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

The Vice President of Provider Contracting and Value-Based Partnerships will provide administrative and management support necessary to achieve the goals and objectives of MetroPlus Health , specifically as they relate to ensuring a comprehensive cost efficient and accessible provider network that is contracted and linked to appropriate fee schedules. Also, this position will serve as the organization’s senior leadership liaison, on contracting matters with all departments involved in contracting processes.

Scope of Role & Responsibilities :

• Negotiate contracts and manage relationships with participating Hospitals, IPAs, Ambulatory Surgery Centers, SUD sites, Behavioral Health Providers, Urgent Care facilities, and Physician Groups and key specialty providers (e.g., Optometry).
• Help develop both the short- and long-term network and contracting strategies for the Plan.
• Manage the Senior Director to ensure end-to-end contracting process, including outreach, recruitment, contract initiation, amendment mailings, and provider non-renewals and terminations.
• Develop in conjunction with Executive Leadership a comprehensive Value Based Payment strategy with key provider partners.
• Coordinate with the Director of Credentialing and Credentialing Department.
• Coordinate with the Director of Provider Data Management, and the Provider Maintenance Department.
• Coordinate with the Director of Special Investigations Unit and the SIU Department.
• Negotiate and review all existing and proposed hospital and large provider contracts. Ensure that reimbursement is competitive, and appropriate for the facility, for the product line, and identify cost saving opportunities for MetroPlusHealth.
• Manage both the Physical and Behavioral Health provider network; ensure adequacy; ensure payment is competitive and meets regulatory guidance.
• Coordinate MetroPlusHealth’s network development and contracting strategy as MetroPlusHealth expands into new lines of business.
• Work with Legal to review and modify any negotiated provider contract language changes as necessary and appropriate.
• Manage an Out-of-Network strategy that addressed high cost out-of-network cases for all lines of business, but primarily for the Commercial and Exchange products.
• Manage the process for Single Case Agreements and work closely with Legal and Regulatory on Independent Dispute Resolution processes :
• Supervise a team of : Senior Director, Director, and Managers and manage the budget for the entire department.
• Providing support necessary for the development of policies and strategic direction for expansion of a comprehensive network.
• Work with Finance and Analytics & Reporting Departments on rate development and related activities, specifically as they relate to the evaluation and analyses of reimbursement structures consistent with industry norms and trends and cost containment initiatives.
• Work with Analytics & Reporting Department and Reimbursement team to address all contract-monitoring activities, specifically as they relate to providers’ compliance with contract terms and conditions.
• Collaborate with MetroPlusHealth departments in the development and evaluation of proposals for operational improvements and new products and make recommendations as they relate to improved performance and cost effectiveness.
• Assist Sales and Provider Network Operations Departments in directing and maintaining relationships with providers through education and provider relations efforts, including assistance in Marketing initiatives to promote membership growth.
• Perform other related functions as required.

Required Education, Training & Professional Experience :

Licensure and / or Certification Required :

Professional Competencies :

#LI-Hybrid

#MPH-50