Sr Dir of Provider Network Strategy

Summary:

The Senior Director of Provider Network Strategy and Management is responsible for developing, implementing and managing the plan's provider network strategy for commercial and government program lines of business in accordance with financial, operational and quality objectives to include: provider network development and expansion, network design, network performance optimization, provider engagement initiatives, and provider reporting and data operational efficiencies. This includes the development and enhancement of relationships with health systems, PHO’s, and provider group executive leadership. The Senior Director oversees all aspects of the provider contracting, provider operations and provider relationship management, provider communication, provider education and relations, provider enrollment and credentialing and provider appeals. Works seamlessly with the analytics department in finance to produce financial modeling and analysis in preparation of contract proposals and renewals. Serves as a key contributor in the development of company strategy, priorities and business planning. The Senior Director is a strong advocate for provider focus for the enterprise as well as for provider contracting, provider relations and seamless provider operations.

Essential Functions:

Develop and Implement Network Strategy

• Leads and drives a customer focused culture throughout their team to deepen client relationships and leverage broader business relationships, systems and knowledge.
• In the relationship with Baystate Health System, focuses on integration and value-based contracting to push toward a truly integrated health system and to advance other system level priorities
• Builds a high performance environment and implements a people strategy that attracts, retains, develops and motivates their team by fostering an inclusive work environment and using a coaching mindset and behaviors; communicating vison/values/business strategy; and, managing succession and development planning for the team.
• Responsible for provider network development and contracting strategy in conjunction with company priorities for all lines of business (Commercial, Medicare and Medicaid), including the evaluation of new business opportunities.
• In conjunction with Health New England's (HNE) Finance staff, creates and monitors annual provider contract budget targets.
• Directs and collaborates with HNE teams performing financial modeling and analysis for provider contracts language, rates, and risk model negotiation.
• Oversees the negotiations and monitoring of provider incentive programs to ensure the achievement of financial, quality, and clinical objectives through accomplishment of provider initiatives
• Leads the investigation and implementation of new payment models such as Shared Savings models, Value Based Contracts, GIC payment reform initiatives, capitation models and bundled payments to support company goals/benchmarks for population health metrics on quality and cost of care and member satisfaction
• Acts as a lead negotiator for PHO/ACO and hospital system contracts
• Works with Director of Financial Services and Director of Quality and Population Health Analytics to create assessment methods and tools to measure provider performance against HNE targets to drive cost and quality improvement
• In collaboration with Finance area and Executive Leadership Team (ELT), develops and executes enterprise network performance improvement strategy related to provider performance on quality, medical expense, member outreach and risk adjustment.
• In partnership with HNE's Finance and Quality areas, designs, implements and monitors the success of a Provider Performance Reporting team to deliver reports and engage provider buy-in with initiatives that will enhance provider’s performance in delivering high quality, cost effective care that optimizes the member’s health and HNE’s Quality results.
• Keeps abreast and maintains familiarity with industry and government program (Medicare and Medicaid) trends, regulations, legislation, and payment rules and reimbursement methodologies
• Participates in company strategy, policy and business planning.
• Member of the Medical Trend Committee: evaluate impacts of provider reimbursement changes on premium rate development
• Provides support for development of new products and premium rates
• Collaborates with HNE's Legal department and outside counsel to resolve contract disputes
• Promotes HNE and its initiatives to outside parties.
• Direct Network Strategy and Provider Contract Review meetings

Seamless provider operations

• Member of HNE's Directors' Team, participating in companywide goals and initiatives. Communicates and educates on the importance of seamless provider operations and positive provider relationships with the organization
• Supervises Provider Relations and Provider Appeals function, Provider Credentialing and Enrollment, and Provider Contracting teams
• Ensures that relationships with providers are appropriately monitored and maintained to drive high provider satisfaction
• Monitors and reviews provider satisfaction results and makes recommendations for improvements
• Collaborates with internal departments to assess provider experience and identify areas of opportunity. Coordinates integration opportunities between internal departments connected with seamless provider operations
• Ensures provider education (new provider orientation, on-going provider visits and meetings, Provider Manuals, Bulletins, Newsletters) activities are done in a timely and cost-effective manner to continuously improve relationships with network providers
• Designs and implements innovative Provider Engagement programs to build loyalty and allegiance to HNE.
• Acts as liaison between provider leadership and health plan senior leadership
• Establishes and reports key metrics to track department performance
• In conjunction with Revenue and Audit teams, monitors for accurate implementation of payment provisions
• Participates in Company-wide and Plan quality initiatives such as HEDIS, CAHPS and NCQA

Staff management and development

• Manages, trains, coaches, and develops associates across the Provider Network Operations departments
• Develops staffing models and monitor capacity/capabilities of Teams across the Provider Network Operations departments
• Leads Teams in a manner that promotes the ongoing growth and expanded knowledge of associates
• Supports team members in the identification of operational barriers and creative problem resolution for improved processes and expanded use of technology
• Communicates to team members regarding HNE priorities and projects that are critical to HNE’s continued success
• Supports collaborative team efforts that produce effective working relationships and trust in accordance with HNE’s high performance culture
• Manages staff workflow and priorities

Minimum Requirements:

• Master's degree in Business, Healthcare Administration or related field; preferred minimum of 7 years of managed care contracting and negotiation experience and at least 5 years in management/leadership role(s). An equivalent combination of education and experience also considered.
• Demonstrated negotiation and influencing experience
• Strong knowledge of commercial and government provider reimbursement methodologies and a variety of risk sharing models
• Expertise in Medicare and Medicaid payment rules and methodologies
• Ability to use financial and utilization data to formulate rate proposals within budgeted financial targets and evaluate financial impact of changes in payment terms
• Strong analytical skills
• Proficient in Microsoft Word, Excel and PowerPoint
• Initiative and ability to solve problems at the strategic and tactical level
• Demonstrates solid communication, interpersonal, and relationship-building skills
• Ability to form and lead teams as necessary for development, and implementation of HNE new or modified policies, programs or processes to support provider contracting objectives
• Demonstrates team leadership, facilitation and coaching skills