Lead Director, Provider Performance Value-Based Care

Responsibilities

• Establish and maintain productive value-based relationships with key network providers.
• Develop and manage the Keystone Value-based Network as outlined.
• Build strategic relationships with provider partners to develop innovative value-based solutions to meet total cost and quality goals.
• Develop alternative payment models, identify and plan new initiatives, and negotiate high value/risk contracts with the most complex arrangement structures.
• Understand providers’ volume and cost structure and work cross-functionally to identify levers and critical negotiation points.
• Align negotiation strategies and tactics with network accessibility, quality, compliance and financial performance goals.
• Manage the value-based contracting cycle from planning, creating documents, negotiation and loading of executed arrangements.
• Work with Performance team, Clinical Transformation team, VBS Analytics team and other key internal teams to develop a value-based strategic plan and oversee contract performance with targeted provider groups.
• Evaluate, help formulate, and implement network strategic plans to achieve value-based contracting targets and manage medical costs through effective value-based contracting.
• Provide assistance and support to other departments, as needed, to obtain crucial or required information from providers, such as HEDIS, Credentialing, Grievance and Appeals, SIU, etc.
• Coordinate provider status information with member services and other internal departments.
• Lead work and deliverables of complex projects/programs, through assessment to implementation, that may impact multiple processes, systems, functions, and products across all lines of business.
• Facilitate and attend external provider meetings and negotiations, as needed.

Requirements

• 10 years of related experience and comprehensive level of negotiating skills with successful track record negotiating value-based contracts with IPAs, large complex provider systems or groups, hospitals, and large physician entities.
• Experience reviewing medical claims data and developing executive summaries and identifying opportunities for mitigating medical cost trends.
• Excellent analytical and problem-solving skills.
• Strong communication, negotiation, and presentation skills.
• Ability to work in a matrixed organization and gain consensus and share information to various interested parties.

Preferred Qualifications

• Familiar with legal terms in the context of provider contracting.
• Familiar with CMS Stars and HEDIS technical specifications and various measurable percentiles associated with the HEDIS measures.
• Experience with Commercial, Medicare and Medicaid contracting.
• Able to apply system thinking when managing multiple provider value-based initiatives.
• Strong financial modeling background.

Pay

The Typical Pay Range For This Role Is $100,000.00 - $231,540.00. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program.