Director, Value-Based Care and Network

1 month ago

Worcester, United States Central Mass Health LLC Full time
Job DescriptionJob DescriptionDescription:


Mass Advantage is a Medicare Advantage health plan, located in Worcester, MA. We are affiliated with the largest health care system in Central Massachusetts, UMass Memorial Health. They are the clinical partner of the University of Massachusetts Chan Medical School, with access to the latest technology, research and clinical trials.


We are seeking a Director of Value-Based Care and Network to lead and execute Mass Advantage’s value-based care (VBC) and network strategy, by leveraging their deep expertise of Medicare Advantage-based network expansion, VBC contracting, and contract performance.


This position is hybrid (remote/office). The individual must be based near Worcester County with regular travel to the office and network practices.


VBC Program Management

  • Accountable for performance of all VBC programs including goals, risk structures, operations, monitoring, and reporting.
  • Negotiate, execute, and manage VBC contracts and bring solutions to optimize performance across key contract levers, including but not limited to attribution, risk adjustment, STARs, and other relevant elements
  • Identify opportunities for performance improvement through ongoing data-driven analysis by reviewing retrospective trends, concurrent leading and process indicators, and predict prospective performance.
  • Own relationships with contracted providers and practices.
  • Drives industry best practices and performance results developing and focusing on driving key KPI’s (e.g., members seen annually by provider, RAF score, quality/STARs, and utilization benchmarks) to ensure accountability across the organization for each contract.
  • Provide plan leadership timely updates on program performance, risks, and predictions along with solutions and mitigations to resolve.
  • Partner with and manage external vendors to execute VBC strategy.
  • Support plan risk adjustment, quality, and care management programs by surfacing opportunities to detail network partners to drive performance and identify which members/practices may benefit from clinical or other programs.
  • Works closely across departments, including Plan Operations, Clinical, Quality, Compliance, Finance, and Sales and Marketing.
  • Ensure that the program meets full compliance with state, federal and partner requirements.

Network Management

  • Lead Provider Relations team around Provider Network management, including ongoing credentialing, provider data management, and pursuing network growth opportunities.
  • Manages contracting and negotiations for fee for service and value-based reimbursement with hospitals and other provider types to ensure performance and network adequacy.
  • Builds relationships that nurture provider partnerships and seeks broader value-based business opportunities to support the local market strategy.
  • Manages strategic positioning for provider contracting, develops networks and identifies opportunities for greater value-orientation and risk arrangements.
  • Serve as a subject matter expert on network dynamics, monitor and evaluate industry news and regulatory changes for impacts to strategy and opportunities.
  • Manage network-related vendor relationships along with identifying and implementing network solutions based on strategic initiatives.
  • Develop management process around contracting and cross-functional dependencies (eg. utilization management, enrollment and attribution, and claims).
  • Contributes to the development of alternative network initiatives. Supports and provides direction to develop network analytics required for the network solution.
  • Works to meet unit cost targets, while preserving an adequate network, to achieve and maintain Mass Advantage’s competitive position.
  • Prepares, analyzes, reviews, and projects financial impact of larger or complex provider contracts and alternate contract terms.
  • Assists in resolving elevated and complex provider service complaints. Research problems and negotiate with internal/external partners/customers to resolve highly complex and/or escalated issues.
  • Manages key provider relationships and is accountable for critical interface with providers and business staff.
  • Demonstrates knowledge of providers in an assigned geographic area through understanding the interrelationships as well as the competitive landscape.
  • Responsible for accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance.
  • Ensure that the program meets full compliance with state, federal and partner requirements including, but not limited to, network adequacy submissions, provider manual oversight and auditing, and website/directory updates.
  • Other job duties may be assigned.

* Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Requirements:

Education and/or Experience

  • Bachelor’s degree in business, healthcare administration, or related field; or equivalent combination of education and experience.
  • 8+ years of successfully leading and executing a comprehensive VBC Risk program/contracts and network management & contracting preferably in Medicare Advantage and/or managed care.
  • Minimum 5 years of healthcare experience with knowledge of health plan operations i.e. Claim processing, customer service, enrollment etc.
  • Minimum 3 years of healthcare experience around risk adjustment and quality and impact to provider workflows

Other Qualifications

  • Proven track record of working collaboratively with clinical and operational colleagues across the organization.
  • Ability to communicate effectively.
  • Ability to lead by influence to engage colleagues and lead teams cross-functionally.
  • Experience in fostering networks with internal and external stakeholders.
  • Possess strong business acumen, excellent strategic thinking, and effective problem-solving skills.
  • Excellent verbal and written communications skills with demonstrated ability to communicate, present, and influence both credibly and effectively at all levels of an organization, including executive and C-level.
  • Proven ability to independently lead complex projects requiring cross functional alignment.
  • Ability to be highly organized and systematic.
  • Ability to provide guidance or expertise to less experienced specialists.

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