Lead Director, Network Management

2 weeks ago

Austin, United States CVS Health Full time

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

**Position Summary**

The Lead Director will manage the development of contracts and agreements with providers and delivery systems in conjunction with being accountable for designing conceptual models, initiative planning, and negotiating high value/risk contracts with the most complex and challenging, market/region/national, largest group/system or highest value/volume of spend providers in accordance with company standards in order to maintain and enhance provider networks, while working cross functionally to ensure consistency with all contracting strategies and meeting and exceeding accessibility, quality, compliance, and financial goals and cost initiatives. Negotiates and executes, conducts high level review and analysis, dispute resolution and/or settlement negotiations of contracts with larger and more complex, market-based, group/system providers. Manages contract performance and supports the development and implementation of value-based contract relationships in support of business strategies. Recruits providers as needed to ensure attainment of network expansion and adequacy targets. Accountable for cost arrangements within defined groups. Collaborates cross-functionally to manage provider compensation and pricing development activities, submission of contractual information, and the review analysis of reports as part of negotiation and reimbursement modeling activities.

Responsible for identifying and managing cost issues and initiating appropriate cost saving initiatives and/or settlement activities. Assists with the design, development, management, and or implementation of strategic network configurations and integration activities. Drives or guides development of holistic solutions or strategic plans negotiates and executes contracts with the most complex, market /region/national, largest group/system or highest value/volume of spend providers with significant financial implications. Recruits providers as needed to ensure attainment of network expansion and adequacy targets. Accountable for cost arrangements within defined groups. Collaborates cross-functionally to manage provider compensation and pricing development activities, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities. Responsible for identifying and managing cost issues and collaborating cross functionally to execute significant cost saving initiatives. Represents company with high visibility constituents, including customers and community groups. Promotes collaboration with internal partners. Evaluates, helps formulate, and implements the provider network strategic plans to achieve contracting targets and manage medical costs through effective provider contracting to meet state contract and product requirements.

Collaborates with internal partners to assess effectiveness of tactical plan in managing costs. May optimize interaction with assigned providers and internal business partners to facilitate relationships and ensure provider needs are met. Ensures resolution of escalated issues related to contract interpretation and parameters. Interprets contractual requirements including federal and state regulations and NCQA. Participates in JOC meetings. Promotes and educate providers on cultural competency. Sets specific, challenging and achievable objectives and action plans. Manages complex, contractual relationships with providers according to prescribed guidelines in support of national and regional network strategies. Mentor and coach new/more junior staff to educate and inform on accreditation and regulatory standards as well as policies on credentialing and re-credentialing.

**Required Qualifications**
- Minimum 7+ years related experience and expert level negotiation skills with successful track record negotiating contracts with large or complex national vendors/providers.
- Proven working knowledge of provider financial issues and competitor strategies, complex contracting options, financial/contracting arrangements, and regulatory requirements.
- Demonstrated ability to identify and manage initiatives that improve total medical cost and quality.
- Health Plan/Payer or Provider Systems experience

**Preferred Qualifications**
- Medicaid regu

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