Director of Network Development and Contracting
Company: Common Ground Healthcare Cooperative
Location: Brookfield
Posted on: January 26, 2023
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Job Description:
Director, Network Development and ContractingAbout usCommon
Ground Healthcare Cooperative is a "who" not a "what." As a
cooperative, we are thousands of Wisconsin residents buying health
insurance together, supported by a staff focused on providing the
best possible service to our members. We are a not-for-profit
cooperative, governed by a Board of Directors made up of members
who purchase our health insurance. Any earnings are returned to our
members in the form of lower prices and better services.Our
CultureWe are here because we can make a difference in the lives of
others. We believe that serving our community is meaningful work
and we hold it in the highest regard. We are vibrant, dynamic, and
value-focused individuals who welcome different points of view,
perspectives, and thoughtful solutions to challenges. We encourage
teamwork, integrity, mutual respect, honesty and doing the right
thing. We know the importance of showing appreciation for a job
well done, celebrate our achievements, and make room for fun and
laughter in the workplace.Our JobWe are continuously improving our
efforts to serve our members and lower their overall healthcare
cost through our three key pillars: Advocacy Partnership
Innovation.Does this sound like a culture you'd like to be a part
of?Come join a fun team of committed professionals!Position
Summary:The Director, Network Development and Contracting is
responsible for developing and maintaining optimal contracting
relationships with new and existing providers including our
strategic health system and ACO partners. The Director will
negotiate agreements with a myriad of major health systems,
independent hospitals, medical groups, individual providers, and
ancillary service providers consistent with CGHC's network strategy
and contracting philosophy, and in compliance with all governmental
regulations and requirements. The Director assists in the
development of policies, processes, and their implementation
relating to Provider Contracting. The Director tracks and monitors
the schedules for all contract renewals and terms, ensures accurate
and thorough fee schedule information is obtained and agreed upon
between parties, and works closely with the Network Analytics and
Provider Relations team to support accurate and effective provider
payment operations and cost containment. The Director, Network
Development and Contracting reports to the Vice President, Provider
Contracting and Strategy, and is accountable to for complete,
accurate and timely contract information.Essential Duties,
ResponsibilitiesContracts with providers successfully to implement
CGHC's goals for network adequacy and efficiency, consistent with
strategic goals and objectives. Ability to think strategically,
creatively, and with a legal mind in relation to contract
provisions and reimbursement terms, including deploying a wide
array of complex reimbursement methodologies and programs when
contracting to foster CGHC's continued growth and expansion.
Implements contracts with providers and health systems and ensures
the contract is loaded into CGHC's system timely and accurately.
Optimizes contracts with providers and health systems to improve
health plans financial performance and delivers savings for health
plans membership in the form of premium dollars. Assists in the
development of value-based care arrangements when appropriate and
optimizes the terms to benefit CGHC's continued growth and
expansion. Completes assigned negotiations and renegotiations
utilizing predictive modeling of impacts on financials and makes
recommendations on network expansion and enhancements to CGHC's
Network Strategy Team. Influence and/or provide input to
forecasting and planning activities for the department. Works with
CGHC staff and others to resolve issues related to contract terms
and reimbursements. Develops and facilitates effective
relationships with new and existing providers that extend into CGHC
operations as needed. Deliver on CGHC's network and product
expansion initiatives from a contracting perspective, including
assessment of health system and provider partners and membership
utilization trends to garner the most favorable and compliant
provider network structures. Evaluates the needs of the network for
potential expansion of service areas and/or product offerings.
Completes negotiations for single case agreements with providers on
an as needed basis in accordance with established guidelines in
collaboration with CGHC's Contracting team. Keeps informed of
Federal, State, and NCQA regulations and requirements. Collaborates
with Sales, Marketing, and Product teams to ensure members access
needs are achieved, CGHC networks are comprised of cost-effective
providers, and benefit designs are supported by contracts. Monitors
and reports on network performance, paying close attention to
utilization and cost changes throughout the network. Analyzing
trends and offering ideas, demonstrated with data, for a more
cost-effective provider network. All other projects and assignments
as requested. Bachelor's degree in Business, Finance, Healthcare
Administration, Nursing, or related field, Master Degree preferred.
Ten years of successful and relevant provider contracting
experience at a health insurance company, at least five years of
experience negotiating fixed reimbursement agreements with major
health systems (additional experience working for providers is a
plus). Demonstrated skill in establishing, building and maintaining
professional relationships. Excellent interpersonal and customer
services skills required. Ability to develop and maintain positive
working relationships with both internal and external stakeholders.
Ability to work cooperatively, sensitively, and tactfully, and
maintain composure and professionalism with all levels of staff,
Providers, Members, and the general public required. Experienced in
working with major integrated delivery systems and individual
provider practices, as well as ancillary providers (ASC, DME, Home
Care, Hospice, LTAC, SNFs). History of successful complex contract
negotiations. Advanced understanding of reimbursement terms and
methodologies. Advanced negotiation skills to include implementing
unique contract language that protects CGHC's interests and
membership; and enhance CGHC's financial position with unique and
innovative payment arrangements. Aptitude for identification and
resolution of problems are highlighted throughout career. Skilled
in multiple payment methodologies, including pay for performance,
gain-sharing, risk sharing, look-backs, and settlements.
Knowledgeable with delegated credentialing arrangements and quality
measures. Have developed or contributed to the creation of a
Provider Manual, building provider networks, developing and
dissemination of provider education, surveys, reports, scorecards
and associated materials. Advanced Knowledge of and ability to use
various computer programs such as Microsoft Office including Excel,
Word, and PowerPoint software and programs/systems utilized in data
analysis. Ability to prioritize and organize a diverse workload
required.General Requirements Maintains attendance according to
Company standards Adheres to Company policies and procedures
Ability to treat others with dignity, respect, and courtesy Ability
to maintain patient, employee, and proprietary confidentiality
Ability to communicate effectively in-person and in all forms of
communication Ability to provide professional image and act
professionally Ability to be flexible and adapt to changing
situations Ability to consistently meet or exceed member
expectations in performing own work, and to follow operating
procedures and practices to ensure the highest level of patient/
member safety and care Ability to use effective customer service
techniques and effective interpersonal skills required Ability to
work and problem solve independently as well as an integral part of
a team Ability to learn new information and integrate
processesPhysical Demands and Work EnvironmentReasonable
accommodation can be made to enable people with disabilities to
perform the described essential functions. This position operates
in a clerical, office setting in a very fast paced environment.
This role routinely uses standard office equipment, including
computers, phones, headsets, photocopiers, and fax machines. While
performing the duties of this job, the individual is regularly
required to talk, hear, stand, and walk. The individual must be
able to travel within the state of Wisconsin and able to work
remotely - if necessary.Direct Reports: No direct reports.Primary
Location: Hybrid - CGHC corporate office, 120 Bishop's Way, Suite
150, Brookfield, WI 53005.
Keywords: Common Ground Healthcare Cooperative, Milwaukee , Director of Network Development and Contracting, Executive , Brookfield, Wisconsin
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