Manager - Contract Network Management (Health Plan) Job

Children's Health - HMO Careers

Job Number: 52199

Location: Dallas, TX

Date Posted: 7-12-2017

Description:

POSITION SUMMARY:

This individual will lead a CMCHP contracting staff for the purpose of contracting with providers to participate with CMCHP. The staff will coordinate, negotiate and transact activities of the provider contracting function and aid in formulating and administering organizational policies and procedures. Negotiate hospital, physician groups and ancillary service agreements and oversee external customer service for providers in accordance with CMCHP and government regulations and guidelines.

JOB PROFILE:

  • Typically manages professional staff and/or team leaders over multiple teams.
  • Typical span of control; Administrative 8- 10, Clinical 10 - 13, Support Services 11- 13.
  • Accountable for the performance and results of a team or multiple teams within own discipline.
  • Adapts unit plans and priorities to address resource and operational challenges.
  • Provides guidance, coaching and feedback to team leaders on effective management techniques.
  • Makes employment decisions for the team, seeking direction from more senior leaders on more complex situations.
  • Decisions are guided by policies, procedures and functional priorities; receives guidance from a higher level Manager on high impact decisions.
  • Monitors quality metrics and changes in practice that impact clinical, financial or operational outcomes and develops action plans to address areas for improvement.
  • Provides guidance to others as needed for non-routine and/or complex problems/situations.
  • Monitors and manages a budget for defined area of responsibility.

JOB SPECIFIC RESPONSIBILITIES:

  • Lead provider contracting and relations activities to ensure efficiency and maintain compliance with CMCHP policies and standards, government laws and regulations.
  • Effectively negotiate contracts with hospitals, physician groups, ancillary providers and LTSS providers to support CMCHP financial and access goals.
  • Develop and implement a network development plan for the assigned region and set of provider and identify and initiate contractes with potential providers in support of the Health Plan's strategic goals and objectives.
  • Effectively integrate new programs and strategies to reach per member per month targets and provide oversight to the provider set up and contract configuration in the computer system to ensure accurate claims adjudication.
  • Perform basic financial analyses to identify medical cost improvement opportunities, develop strategies to reach financial goals and executes contracting strategies to meet goals and objectives.
  • Develop financial modeling tools as necessary.
  • Evaluate and monitor providers performance standards and financial performance of contracts and implement creative solutions for underperforming contracts.
  • Develop staff skills and competencies through training and experience.
  • Work with Provider Relation Staff to establish and maintain strong business relationships with networks providers.
  • Maintain expert level knowledge of Medicaid reimbursement methodologies.
  • Provide effective provider outreach and support.
  • Leads monthly Joint Commission Committee meetings with key providers.
  • Ongoing gap analysis for network adequacy.

QUALIFICATIONS:

Experience:

  • Three plus years of related experience negotiating hospital, large physician groups for Health Plan and ancillary service agreements, including experience with providing external customer service for providers.
  • Expereince in claims processing, marketing/sales, medical economics in a managed care or insurance environment.
  • Proven experience with diverse payment structures such as experience in Medicaid and CHIP reimbursement experience, capitation, DRG, case rates, carve outs and other risks.

Education:

  • Bachelor's Degree or equivalent experience.

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