Senior Network Contractor – Cypress, CA
Details: The Senior Network Contractor is responsible for developing the provider network (physicians, hospitals, pharmacies, ancillary groups & facilities, etc.) yielding a geographically competitive, broad access, stable network that achieves objectives for unit cost performance and trend management, and produces an affordable and predictable product for customers and business partners. Evaluates and negotiates contracts in compliance with company contract templates, reimbursement structure standards, and other key process controls. This candidate will establish and maintain strong business relationships with Hospital, Physician, Pharmacy, or Ancillary providers, and ensures the network composition includes an appropriate distribution of provider specialties. Primary Responsibilities: Demonstrate understanding of applicable products for different lines of business (e.g., Employer and Individual; Medicare and Retirement; Community and State) Analyze UCRT associated with products, markets, and/ or providers to assess performance against budget Evaluate current contract performance to identify potential remediation opportunities and/or cost savings Demonstrate understanding of and utilize applicable financial tools (e.g., HPM; PPM; FAT; HCE’s RVU/Unit tool) and reports (e.g., internal financial models; external reports) to evaluate performance of current contracts and develop rates Demonstrate understanding of competitor landscape within the market (e.g., rates; market share; products; provider networks; market intelligence; GeoAccess) Balance financial and operational impact of contracts to providers, members, UHN, and different customer groups when developing and/or negotiating contract terms Weigh financial and operational information to evaluate continued provider participation Interact and consult with Network Pricing team to evaluate different financial arrangements and to identify and recommend applicable payment methodologies (e.g., FFS; Case Rate; Sub-capitation; Pay for Performance) in order to maximize value for stakeholders Utilize appropriate contract management systems (e.g., Emptoris; PEGA; Contract Attachment Repository) to author and execute contracts and to access supplemental contractual documents Demonstrate understanding of submission tools (e.g., Delegation Authority Grids; loading grids; Navigator; BPM) to ensure accurate and timely contract configuration for customer groups Evaluate market rates and provider performance (e.g., billing patterns; referral patterns; quality and effectiveness) in order to establish provider rates and negotiation strategies Communicate proposed contractual terms with provider and negotiate mutually acceptable agreement Explain the organization’s direction and strategy to internal partners and providers in order to justify methodologies, processes, policies, and procedures Demonstrate benefits of applicable reimbursement methodology to internal partners and providers Identify and gather information regarding provider issues in order to develop and/or implement strategy to resolve matter, keep manager informed of progress, or escalate issue to appropriate internal business partner Represent department in external meetings (e.g., ancillary providers; physician groups; facilities) to gather relevant information, recommend solutions, execute on deliverables as assigned and explain results/decision/activities Report back information from provider meetings to applicable stakeholder (e.g., manager; business partner) in order to determine appropriate action Monitor and/or oversee provider financial performance to identify opportunities to improve performance and/or provider relationship Communicate contractual and/or operational performance to providers to ensure compliance with contractual terms and protocols Educate providers on the organization’s processes, policies, and procedures in order to ensure provider compliance and ease of Administration Implement local, regional, and/or national initiatives and directives (e.g., ICD10; medical necessity language) through contracting strategies and communication efforts Identify and share best practices (e.g., payment methodologies; negotiation tactics) with national and regional colleagues Modify and/or develop new payment methodologies in order to execute market strategies Present and discuss industry and market trends with internal and/or external groups (e.g., customer groups; brokers; professional associations; providers) in order to facilitate market strategy development and implementation Monitor and/or oversee network performance and industry trends to identify opportunities to refine, develop, and/or implement market strategies Represent department in internal meetings (e.g., medical management; M&R; C&S) to gather relevant information, present/recommend solutions, and provide updates on results/decision/activities Develop and/or implement contracting strategies to support new benefits designs and plansApply for this job.