Director of Network Development and Contracting

Company: Common Ground Healthcare Cooperative
Location: Brookfield
Posted on: January 26, 2023

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