The Director, Provider Network Management (PNM) with Health Alliance Plan (HAP), will be responsible for provider contracting and management of provider relations for assigned accounts using a coordinated team approach including the Director, and contract and provider services administrators. HAP's focus is to move providers into alternative payment model (APM) contracts that reward HAP and providers for managing cost, quality and the member experience. Our PNM Directors then help providers maximize the value of APM contracts to realize total cost of care (TCOC) incentives, quality and other bonuses, TCOC budgets that recognize member medical demand through appropriate risk score recognition, general performance improvement initiatives (e.g. leakage avoidance) and member growth.
The Director is responsible for developing the strategic direction for regional markets under their supervision, generating data driven recommendations for provider strategic relationships and direction of key operations related to network development, physician/hospital contracting, APM contracts, provider services and improving network performance within a defined market. The Director will lead a team and identify opportunities for reducing the cost of care, achieving desired quality results using Medicare Star, Medicaid and HEDIS, cost containment and member satisfaction. Through leadership to direct staff, the Director will engage employees, manage performance, growth and development.
Principal Duties and Responsibilities :
Expand in network physicians and hospitals in alternative payment methods defined by the PNM VP.
Develops and executes new value based contracting models
Develops and executes programs across the continuum of alternative payment methods.
Develops along with Plan Executives the quality programs supporting STARS and other corporate quality initiatives.
Responsible for end-to-end management of provider relationships for designated accounts including contracting, onboarding, claims processing configuration data preparation based on negotiated contracts, provider performance improvement and strategic relationship development.
Develops, negotiates, and implements provider contracts including, APM contracts with key provider groups. Leads contract preparation, devises objectives and strategy, manages negotiation within prescribe timelines, and documents contract terms with the assistance of legal counsel and other business unit subject matter experts.
Oversees claims processing configuration data preparation for negotiated contracts and coordinates activities with Provider Reimbursement and Business Configuration Team to support contract implementation. Executes data quality control and hygiene activities to assure collection of high-quality data.
Directly works with PHOs/POs/IPAs/Clinically Integrated Networks (collectively APM Entities or APMEs) to secure provider performance improvement including HEDIS, Medicaid and Medicare Star rating program, risk adjustment data collection, high performing provider referral management and leakage avoidance, total cost of care management (TCOC) s, and documentation of the data exchange and actionable information workflow with APMEs to support APM operations and performance improvement.
Responsible for developing strategic partner relationships after evaluation of market alternatives and with a clear plan to realize value for HAP, including member growth.
Cultivate accountable relationships between key leaders in the network and within HAP. Functions as a liaison between operational leadership within HAP and APME administrative staff and physicians to ensure positive provider working relationships are established and maintained.
Use actionable information to drive HAP and provider performance. This requires the ability to meet each group where they are in the continuum of APMs. Continually identifies opportunities for provider performance improvement and supports APME efforts to achieve results with relevant information and metrics. Identifies HAP support needed to ensure success.
Assess value-based risk readiness of all providers/facilities.
Monitor financial, quality, member experience and member growth results for the APMs, and coordinates financial reconciliations and incentives with finance department. Communicates results to groups consistently and periodically as needed. Adept at understanding reports and actionable information to guide provider performance improvement.
Develop and maintains purposeful long-term partnerships based on fair/competitive business terms, centered on improving the delivery of care and creating mutual rewards based on performance that result in in improvements in cost, member satisfaction and outcomes.
Work with external resources to oversee event planning for physician focused events, relative to provider education, physician recognition and community-based provider educational initiatives.
Performs other related duties as assigned.
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Education Required :
Bachelor's degree, in healthcare, sciences, or informatics or related field.
Master's degree preferred.
Experience Required :
Minimum of seven (7) years' experience in the health care field with three (3) years provider contracting experience with hospitals, health systems and professionals. Experience working with provider groups and health systems, and knowledge of value-based operations preferred.
Minimum of three (3) years' experience in direct management of staff.
Strong contextual knowledge of provider contracts and market strategies with subject matter expertise in managed care, provider reimbursement models, national health care trends, practice management trends, risk assessment, and provider performance improvement.
Skills and Abilities :
Exceptional management organizational and administrative skills.
Personal and professional integrity and superb communication skills, both oral and written, to internal and external audiences.
Team player with proven ability to develop strong working relationships and to mentor the team to highest capability and superior performance.
Must be proficiency with Microsoft Office programs with Visio a plus.
HFHS and HAP Team Member Standards of Excellence :
Must meet or exceed core customer service responsibilities, standards and behaviors as summarized below:
Display a positive attitude
Take ownership and be accountable
Offer open and constructive communication
Respond in a timely manner
Take pride in the Henry Ford Health System and HAP
Respect and be sensitive to privacy/confidentiality
Commit to team members and their personal and professional development
Honor and respect diversity
Maintain a clean and safe workplace environment
Physical Demands/Working Conditions :
Typical office environment
Sedentary - Exerts up to 10 lbs. of force occasionally to lift, carry, push, pull, or otherwise move objects, including the human body. Involves sitting most of the time but may involve walking or standing for periods of time.
Talking - Expressing or exchanging ideas by means of the spoken word.
Hearing - Perceiving the nature of sounds
Work from Home permitted except for occasional team huddles in office; this requirement may shift to in market / office attendance as reasonably determined by HAP.
Additional Information
Organization: HAP (Health Alliance Plan)
Department: Provider Contracting
Shift: Day Job
Union Code: Not Applicable
Additional Details
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.
Overview
Partnering with nearly 2 million peopl
